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MANUAL OF OTOLOGY 



STUDEXTS AXD PRACTITIONERS 



BY 

CHARLES EDWIN PERKINS, M.D., F.A.C.S. 

PROFESSOR OF CLINICAL OTOLOGY IN NEW YORK UNIVERSITY AND 
BELLEVUE HOSPITAL MEDICAL COLLEGE; ASSOCIATE AURAL SURGEON 

TO ST. Luke's hospital; assistant aural surgeon, new 

YORK EYE AND EAR INFIRMARY; FELLOW, AMERICAN 
OTOLOGICAL society, new YORK OTOLOGICAL 
society, new YORK ACADEMY OF 
MEDICINE, ETC. 



ILLUSTRATED WITH 120 ENGRAVINGS 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1916 






Entered according to the Act of Congress, in the year 1916, by 

LEA & FEBIGER, 
in the Office of the Librarian of Congress. All rights reserved. 




AUG 181916 



^CI.A438108 



PREFACE. 



Many years' experience in teaching otology to under- 
graduates and to postgraduate students who are adopting 
it as a specialty has made the author conversant with its 
inherent diflficulties. In the preparation of this manual 
it has been his aim to lighten these difBculties and to 
supply data which will enable those who thoroughly 
master them to become capable aurists. The simpler 
and less serious affections, which fortunately form the 
larger part of aural practice, have been discussed in full 
detail as to their diagnosis and treatment, and the orderly 
sequence in which these topics are taken up should afford 
the reader a properly correlated conception of the entire 
subject. 

In describing operative procedures applicable to the 
middle ear and mastoid, the consideration of many minutiae 
is essential. Careful adherence to the technic advised, 
with due attention to the measures indicated to avoid 
dangers and accidents, will insure the sm^geon's becoming 
a safe and efficient operator.. The chapter on Suppurative 
Diseases of the Labyrinth sets forth tTie present knowledge 
of the graver affections of this complex region. It is 



IV PREFACE 

hoped that this part of the subject has been presented in 
so clear and definite a manner as to bring it even within 
the easy grasp of the beginner. 

The author desires to express his thanks to Dr. E. B. 
Dench, with whom he has been many years associ- 
ated in aural work. He is also under obligations to Mr. 
K. K. Bosse for his work on the illustrations, and to 
the publishers, Messrs. Lea & Febiger, for their care in 
making the book. 

C. E. P. 

New York, 1916. 



CONTENTS. 



CHAPTER I. 

Anatomy and Physiology of the Ear ....... 1 

CHAPTER II. 
Examination of the Patient 47 

CHAPTER III. 

Diseases of the External Ear 84 

CHAPTER IV. 

Diseases of the Membrana Tympani 127 

CHAPTER V. 

NON-SUPPURATIVE DISEASES OF THE IMlDDLE EaR . . . 132 

CHAPTER VI. 
Acute Inflammation of the Middle Ear 164 

CHAPTER VII. 
Mastoiditis 189 

CHAPTER VIII. 
Sinus Thrombosis 235 



vi CONTENTS 

CHAPTER IX. 

Otitis Media Purulenta Chronica 249 

CHAPTER X. 

Suppurative Diseases of the Labyrinth oOO 

CHAPTER XI. 

Complications of Purulent Otitis Media 343 

CHAPTER XII. 

NON-SUPPURATIVE DISEASES OF THE InNER EaR .... 379 

CHAPTER XIII. 

General Aural Diseases 402 

CHAPTER XIV. 
Tinnitus Aurium 419 



MANUAL OF OTOLOGY. 



CHAPTER I. 

ANATOIVIY AND PHYSIOLOGY OF THE EAR. 

The ear may be divided into three parts: the external, 
middle, and internal. The external and middle are con- 
cerned in transmitting sonorous vibrations and are 
therefore called the sound-conducting mechanism. The 
inner ear consists of the acoustic and static labyrinths. 
The acoustic labyrinth (the cochlea) with its central 
connections receives and analyzes sonorous vibrations, 
and is called the sound-perceiving mechanism; while 
the static labyrinth (consisting mainly of the semicircular 
canal system) with its central connections, is concerned 
in the maintenance of equilibrium. 

EXTERNAL EAR. 

The external ear is that part of the auditory apparatus 
which is situated external to the membrana tympani, and 
consists of the auricle and auditory canal or meatus. 

Auricle. — The auricle or pinna is an irregular, oval- 
shaped appendage, composed of a cartilaginous frame- 
work covered with integument. It is attached to the 
side of the head at an angle so that its posterior surface 
is directed internally, and its anterior surface is directed 
externally. Its posterior surface is comparatively smooth, 
while its anterior surface is irregular and more or less 
concave, thus acting to collect sound waves and conduct 
2 



18 ANATOMY AND PHYSIOLOGY OF THE EAR 

them into the external auditory canal. It presents numer- 
ous eminences and depressions. These vary in different 
subjects, both in size and position, but it is usually not 
difficult to identify t,hose shown in the cut (Fig. 1), a 
study of which conveys a very good impression of the 
name and location of these eminences and depressions. 



DARWINIAN 
TUBERCLE 



rOSSA 

TRIANGULAniS 



CRURA or 

ANTIHELIX 




cRus or 

HELIX 



INCISURA 
ANTERIOR 



TUBERCULUM 
SUPRATRAGICUM 



EXTERNAL 
AUDITORY 
MEATUS 



INCISURA 
INTERTRACICA 



POSTERIOR 

AURICULAR 

SULCUS 



CAVUM CONCHAE 

Fig. 1. — Anterior and external view of the auricle. (Gray.) 



The muscles of the ear are rudimentary in man and not 
of surgical importance. The auricle is attached to the 
temporal bone by three ligaments — the superior, anterior 
and posterior — w^hich extend from the cartilaginous frame- 
work of this structure to the bone forming the entrance 
to the external auditory canal. 

The blood supply of the auricle is received through the 



EXTERNAL EAR * 19 

posterior auricular from the external carotid, the anterior 
auricular and some smaller branches from the temporal. 

The nerves are the auricularis magnus from the cervical 
plexus, the auriculotemporal, T\'hich is a branch of the 
inferior maxillary nerve and some small branches of the 
small occipital nerve. 

Meatus. — The external auditory canal is about one and 
a half inches long if measured from the tragus. A little 
more than the outer half is cartilaginous and membranous, 
the remaining inner part being osseous. If measured 
from the bottom of the concha, it is about one inch in 
length, of which the outer third is cartilaginous. The 
cartilage extends deeper on the anterior than on the pos- 
terior wall and is traversed by two vertical fissures (the 
fissures of Santorini) through which infective processes 
or purulent accumulations may extend from the canal 
to the tissues anterior to the ear. The membranous and 
osseous portions of the meatus form an obtuse angle with 
each other, the outer part having a direction upward, 
backward, and inward; while that of the inner part is 
downward, forward, and inward. The integument lining 
the outer part contains the openings of the ceruminous 
glands, and from it project the hairs of the meatus. These 
structiues are found only in the cartilaginous, never in 
the osseous portion of the canal — a point of practical 
importance in the study of certain diseases affecting the 
external auditory canal. Slightly internal to the junction 
of the two parts the canal is usually contracted by the 
prominence of the anterior bony wall. This constricted 
portion is called the isthmus. Internal to this the canal 
usually widens anteriorly, forming a depression which 
extends to the membrana tympani. This renders it 
difficult at times to obtain a view of the extreme anterior 
part of the drum membrane, and also aftords a lodge- 
ment for foreign bodies from which their extraction may 
become difficult. The membrana tympani forms the 
fundus of the canal and lies obliquely, thus making the 
canal deeper anteriorly and inferiorly than above and 



Cartilage oj /^ 

the pinna """"---.^(f^ 



Promont. 




Int. carat, a 



Membrana / • 

tympani / 

Cartilage of the cxt. 
ouditory meatus 



Fig. 2. — Horizontal section of the external auditory meatus and tym- 
panum. (Gray.) 




FENESTRA OVALIS 
LOSED BY STAPES 



Fig. 3.— Vertical section of the external auditory meatus and tympanum. 

(Gerrish.) 



EXTERNAL EAR 



21 



posteriorly (Figs. 2 and 3). The osseous canal is formed 
principally by the outgrowth of the tympanic ring. At 
birth this ring forms an incomplete circle (Fig. 4). The 
part between the ends of the ring is called the segment 
of Rivinus, and is filled in by the squamous portion of 
the temporal bone. In the development of the bone this 
grows pari passu with the outgrowth from the tympanic 
ring and completes the canal above. This takes place 



1 for 
squamous 
porfion, 
including 
zygoma : 
Sd month. 



1 for ti/mpanic 
plate. 



6 for petrous 

and mastoid 

portions. 



2 for styloid process. 

Fig. 4. — Tympanic ring. (Gray.) 




in extra-uterine life. At birth there is no osseous canal, 
the tympanic ring, and therefore the drum membrane 
attached to it, lie practically on the surface. The inclina- 
tion of the drum head is as great or slightly greater than 
in adult life, its external surface being directed downward, 
forward, and outward. The membranous canal is attached 
directly to the tympanic ring and its direction is upward 
and outward, the auricle being placed higher on the 
squama than in the adult. 



22 ANATOMY AND PHYSIOLOGY OF THE EAR 

The nerve supply of the external auditory canal is 
derived from the auriculotemporal, the auricularis mag- 
nus, and the pneumogastric through its auricular branch 
(Arnold's nerve). It is claimed that the facial supplies 
sensory and trophic filaments to the external auditory 
canal and auriqle. This claim is based largely upon 
pathological investigations which are discussed under 
Herpes Zoster Oticus. 

Tympanic Membrane. — The tympanic membrane forms 
the fundus of the external canal and part of the external 
wall of the tympanum and is therefore common to the 
external and middle ear. It is divided into two parts 
which are very unlike in structure and appearance. 
These are the membrana tensa and the membrana flac- 
cida or Shrapnell's membrane. The membrana tensa is 
that part which is attached to the tymi)unic ring; while 
Shrapnell's membrane fills in the Hivinian segment, 
having its peripheral attachment at the internal end of 
the squamous portion of the canal. The meml)raiui 
tensa consists of three layers — an outer one of epithelium 
which is continuous with that lining the meatus; a middle 
one of fibrous tissue, the fibers of which are arranged in 
either a radiating or circular manner and enclose the 
manubrium; while the inner layer is composed of mucous 
membrane which is continuous with that lining the 
tympanic cavity. Shrapnell's membrane is much smaller, 
and is really an extension of the skin of the su])erior canal 
wall, lined to a greater or less extent on its iimer surface 
with the tympanic mucous membrane. 

MIDDLE EAR. 

Tympanum. — The middle ear lies internal to the tym- 
panic membrane. It is an irregularly cuboidal cavity 
and presents six walls for examination: namely, internal, 
external, anterior, posterior, inferior or floor, and superior 
or roof. The cavity lies obliquely so that the internal 
wall is also partly superior. This must be remembered, 



MIDDLE EAR 



23 



but for pjurposes of description is ignored as leading to 
confusion. The internal wall (Fig. 5) is principally 
formed of the bony labyrinth and presents tive points 
for examination, as follows: (1) Superiorly, the promi- 
nence of the anterior end of the horizontal semicircular 
canal. (2) Immediately below this and extending hori- 
zontally is a ridge which is the external wall of the 
tympanic part of the Fallopian canal containing the 



JUNCTION BETWEEN MAS 
TOlO ANTRUM AND 
EPITYMPANIC RECESS 
TEGMEN 
TYMPANI 

EPITYMPANIC 
RECESS 

: OF EXTERNAL 
) CANAL 
PROMINENCE OF AQUEDUCT 
OF FALLOPIUS 

TENDON OF 
STAPEDIUS MUSCLE 
PLICA 
STAPEDIUS 

PROCESSUS 

COCHLEARIFORMIS 

^^ TENSOR TYMPANI 

MUSCLE (cut through) 

WALL OF 
LABYRINTH 



/ PROMINENCE OF 
/ SEMICIRCULAR < 
/ PROMIl 
/ OF FALl 




Fig. 5. — Internal tj^mpanic wall. (Gray.) 



facial nerve. (3) Immediately below this is the oval 
window^ at the bottom of a depression or niche. In 
the recent state the niche is occupied by the stapes, the 
foot-plate of which, together with its annular ligament, 
closes in the oval window. The shell of bone between 
the facial nerve and the oval window is very thin and 
sometimes absent — a point of surgical importance. (4) 
Below and behind the oval window, separated from it 



24 ANATOMY AND PHYSIOLOGY OF THE EAR 

by a process of bone which is part of the promontory, 
is the niche of the round window at the bottom of which 
is the fenestra rotunda, or round window. This is closed 
in by a thin membrane called the membrana tympani 
secondaria. (5) The promontory which lies between 
and anterior to the two fenestrse is of ivory-like bone, 
and a part of the labyrinthine capsule which forms the 
first cochlear whorl or turn. Anterior to this promontory 
the internal wall is receding, and the transverse dikmeter 
of the tympanum greater. The second cochlear whorl 
in this location does not form a prominence as the first. 

The outer wall is formed by the tympanic membrane, 
the tympanic ring, and above by the internal end of 
the superior wall of the external auditory meatus. The 
anterior wall is formed internally by the bone covering 
the carotid canal, while externally is the opening of the 
Eustachian tube, and above this and separated from it 
by a bony process, the processus cochleariformis, is the 
canal for the tensor tympani muscle. The posterior 
wall of the tympanum is absent above on account of the 
opening into the mastoid antrum (additus ad antrum) » 
on the floor of which is the fossa incudis in which lies 
the short process of the incus. Below is the pyramid, 
a hollow bony process, which contains the stapedius 
muscle. The tendon of this muscle emerges at the apex 
of the pyramid and is attached to the posterior crus of 
the stapes. At times there is a recess leading back into 
the bone from the posterior wall, called the sinus tympani. 

The roof, or tegmen tympani, separates the tympanic 
cavity from the middle cranial fossa. It is a thin shell 
of bone and part of the inner table. A few small fragile 
cells may be found in this situation or the bone may 
present defects or dehiscences, thus allowing the middle 
ear to come into still closer relation with the cranial 
cavity. The tegmen is continuous posteriorly with the 
roof of the antrum, and anteriorly with the bone covering 
in the canal for the tensor tympani muscle. The floor 
or inferior wall of the tympanum is in relation with the 



MIDDLE EAR 25 

jugular bulb. The thickness of the bone in this situation 
varies. It may be very thin or even absent. If absent, 
the dome of the jugular bulb may extend into the tym- 
panic cavity. When this condition is present there is 
danger of wounding the vessel in performing the operation 
of myringotomy. This has occurred, but fortunately 
this anomaly, which renders this accident possible, is 
rare. The floor is perforated by a small opening near 
the internal tympanic wall for the passage of the tympanic 
branch of the glossopharyngeal (Jacobson's nerve). 

Eustachian Tube. — The Eustachian tube connects the 
tympanum with the nasopharynx. It is about one and 
a half inches in length. Its external one-half inch is 
osseous and lies adjacent to the tympanic cavity. The 
remaining part of the tube, about one inch in length, is 
membranous and cartilaginous, and is adjacent to the 
nasopharynx. At the junction of these two parts the 
lumen of the tube is contracted and the isthmus is thus 
formed. The inner end is trumpet-shaped, the pharyn- 
geal orifice being much larger than the lumen at the 
isthmus. Its direction is downward, forward and inward, 
the amount of obliquity varying more or less with the 
shape of the skull. The tube is lined with mucous mem- 
brane, covered with ciliated epithelium, continuous 
with the mucous membrane of the t^Tnpanum and naso- 
pharynx. Immediately above the tube and separated 
from it by a thin shell of bone — the processus cochleari- 
formis — is the tensor tympani muscle which arises from 
the base of the temporal bone and adjacent part of the 
Eustachian tube, and is inserted into the manubrium. 

Ossicles. — The tympanic cavity contains the ossicular 
chain (Fig. 6). This consists of the malleus, incus, and 
stapes. The malleus or hammer (Fig. 7) presents a 
head, neck, long and short process and handle for examina- 
tion. The handle or manubrium lies in the tympanic 
membrane and partakes of the movements of this mem- 
brane and affords attachment to the tensor tympani 
muscle. The short process is a small conical process 



26 ANATOMY AND PHYSIOLOGY OF THE EAR 




Firji. 6. — Chain of ossicles and their ligaments, seen from the front in a 
vortical, transverse section of the tympanum. (Gerrish.) 




INSERTION 

OF TENSOR 

TYMPANI 

MUSCLE 



AURICULAR 
SURFACE 
FOR BODY 
OF INCUS 

INSERTION OF 
EXTERNAL 
LIGAMENT 
F MALLEUS 



ORT 
PROCESS 



ANUBRIUM 



Fig. 7. — Posterior view of the right malleus. (Gray.) 



MIDDLE EAR 27 

surmounting the upper end of the handle and is directed 
outward. The long process lies in the Glaserian fissure. 
The neck is the constricted portion of bone connecting 
the handle with the head of the ossicle. The latter 
articulates with the incus. This articulation is of a 
rachet nature and allows the handle to make excursions 
outward without acting upon the incus, but movement 
inward causes the joint to bind and the incus to be moved. 
This is brought about by the teeth or cogs, which separate 
when the manubrium makes an extensive movement 
outward, but come in contact upon inward movement of 
the handle of the malleus. The incus (Fig. 8) presents 




Fig. 8. — Mesial and front view of the right incus. (Graj-.) 

a body which articulates with the head of the malleus, 
a short process which lies in the fossa incudis, and a 
long process which is connected with the capitellum of 
the stapes, forming the incudostapedial articulation. The 
stapes (Fig. 9) or stirrup has a head or capitellum articu- 
lating with the long process of the incus, two crura, an 
anterior and posterior, which connect the head with the 
foot-plate. To the posterior crus is attached the tendon 
of the stapedius muscle. The foot-plate with its annular 
ligament fills in the oval window, forming what is termed 
the stapediovestibular articulation. 

Ossicular Ligaments. — The ossicles are held in position 
by various ligaments which connect them with the 



28 ANATOMY AND PHYSIOLOGY OF THE EAR 

tympanic walls and with each other. The ligaments 
which connect the malleus with the tympanic wall are 
the anterior, external, and superior. The anterior con- 
sists of two parts, the band of Meckel and the anterior 
ligament of Helmholtz. The band of Meckel was for- 
merly considered as a muscle and described as the 
laxator tympani. It is of fibrous tissue and is attached 
at the base of the long process and extends through the 
Glaserian fissure to the spine of the sphenoid. The 
anterior ligament of Helmholtz extends from the neck 
of the malleus to the anterior margin of the Rivinian 
segment. The external ligament extends from the junc- 
tion of the head and neck of the malleus to the posterior 
part of the Rivinian segment. The posterior fibers 




GROOVE FOR 
OBTURATOR 
MEMBRANE 

ANTERIOR if M O'^^^^^^ 

CRUS~ff A \g POSTERIOR 
CRUS 




BASE OF STAPES 

Fig. 9. — The right stapes., viewed from alcove. (Gray.) 

of this ligament constitute the posterior ligament of 
Helmholtz and together with the anterior ligament of 
Helmholtz form what is termed the axis band. The 
superior or suspensory ligament is a small ligament 
extending between the head of the malleus and the 
tegmen tympani. The short process of the incus is held 
in position in the fossa incudis by a band of fibrous 
tissue. The ossicles are connected with each other at 
their articulations by fibrous tissue arranged more or 
less in the form of annular ligaments. 

Mechanism of Ossicular Movement. — The axis band 
above described constitutes the axi3 upon which the 
movement of the ossicular chain takes place. The 
mechanism is a lever the long arm of which is the manu- 



MIDDLE EAR 29 

brium and the short arm the long process of the incus, 
the ratio of the arms being as three to two. The effect 
of this mechanism is therefore to diminish the amplitude 
but to increase the intensity of sonorous vibrations in 
transmitting them from the membrana tympani and 
consequently the manubrium to the stapes, and through 
it to the labyrinthine fluid. The tensor tympani, by its 
contraction, depresses and renders the drum membrane 
tense, causing it to assume a proper condition to be 
affected by sonorous vibrations. The action of the 
stapedius muscle is antagonistic to the tensor tympani, 
as its contraction acts to draw the foot-plate of the stapes 
away from the labyrinthine fluid, thereby diminishing 
intralabyrinthine pressure. Acting thtis it protects the 
delicate structures within the labyrinth against loud 
noises or force exerted inward upon the drum membrane. 
Mucous Membrane. — The mucous membrane of the 
middle ear is continuous with that in the tube and through 
it with the nasopharyngeal mucous membrane. It 
lines the tympanic cavity, the internal surface of the 
drum membrane, and is continuous with the membrane 
in the mastoid antrum and cells. It covers the ossicles 
and their ligaments and in so doing several vascular 
folds are formed. The anterior fold of the malleus extends 
from the anterior end of the Rivinian segment to the 
upper end of the handle of the malleus, and envelops 
the chorda tympani nerve, the long process of the malleus 
and the anterior ligament. The posterior fold extends 
from the upper end of the manubrium to the posterior 
margin of the Rivinian segment, and envelops the pos- 
terior tympanic part of the chorda tympani, and the 
external ligament of the malleus. Both of these folds 
have free concave margins and the depressions lying 
between the folds and the tympanic membrane are 
called the pouches or recesses of von Troltsch, anterior 
and posterior respectively. Prussak's space lies between 
Shrapnell's membrane externally, the neck of the malleus 
internally, and the external ligament posteriorly. Besides 



30 ANATOMY AND PHYSIOLOGY OF THE EAR 

those described above there are various other folds, 
some more or less constant, others peculiar to the indi- 
vidual subject, which are of importance from their role 
in pathological middle-ear processes. Throughout the 
greater part of the tympanic cavity the mucous membrane 
is covered with columnar ciliated epithelium. That cov- 
ering the internal surface of the drum membrane and the 
ossicles is of the squamous non-ciliated variety. 

Arteries. — The arterial supply of the tympanum is 
quite free and derived from various sources. The tym- 
panic branch of the internal maxillary artery enters 
through the Glaserian fissure and anastamoses with 
the stylomastoid branch of the posterior auricuhir which 
gains access to the tympanum through the Fallopian 
canal. Besides these there are the petrosal branch of the 
middle meningeal which enters through the hiatus 
Fallopii, some small branches of the middle meningeal 
entering through the petrosquamosal fissure, branches 
of the carotid reaching the tympanic cavity through the 
anterior tympanic wall, and the tympanic branch of 
the ascending pharyngeal which enters the tympanum 
through the foramen for Jacobson's nerve. 

Nerves. — The nerve supply is derived from the tympanic 
branch of the glossopharyngeal which receives branches 
from the carotid plexus of the sympathetic. These are 
the caroticotympanic and small deep petrosal nerves 
which enter through the anterior tympanic wall. The 
tympanic plexus also receives branches from the superficial 
petrosal nerves. The plexus thus formed lies in grooves 
upon the internal tympanic wall and sends branches to 
the various structures in the middle ear and, according to 
some authors, a branch to the chorda tympani {Ravms 
commiinicans) , The stapedius is supplied by a branch 
from the facial. The tensor tympani receives its nerve 
supply from the otic ganglion. 

Facial Nerve. — The facial nerve as it passes through 
the temporal bone is of great interest to the otologist, 



MIDDLE EAR 31 

both from the symptoms arising from its involvement and 
the danger of its being injured in surgical procedures. 
The deep origin of the facial is from a nucleus in the floor 
of the fourth ventricle, although the fibers supplying the 
occipitofrontalis, the orbicularis palpebrarum and the 
corrugator supercilii, have a different origin and join 
the nerve before it leaves the brain. They are, therefore, 
not involved in nuclear facial paralysis. In the internal 
auditory meatus the nerve lies above and anteriorly, 
being separated from the eighth nerve by the pars inter- 
media of Wrisberg. It enters the superior and anterior 
compartment at the fundus of the internal auditory 
meatus. This is the beginning of the aqueductus Fallopii, 
or Fallopian canal, which passes through the temporal 
bone, containing the nerve which emerges at the stylo- 
mastoid foramen. Its course is at first outward, lying 
in the angle formed by the superior semicircular canal 
and the cochlea. As it comes into relation wdth the 
internal tympanic wall, it turns backward. This part 
of the Fallopian canal (tympanic portion) forms a ridge 
on the internal tympanic wall, which is situated between 
the oval window and the anterior end of the horizontal 
semicircular canal. In this part of its course the tympanic 
wall of the Fallopian • canal not infrequently presents 
defects (dehiscences) which render its involvement in 
middle-ear processes or its injury during an operation 
more apt to take place than when these dehiscences are 
absent. At the posterior tympanic wall the nerve again 
turns, passing directly downward to the stylomastoid 
foramen. In this part of its course it lies immediately 
behind the posterior tympanic wall, at the base of the 
pyramid containing the stapedius muscle, to which it 
gives a small branch. In passing through the temporal 
bone the nerve has thus three directions: the first out- 
ward, lying in the coronal plane; the second backward; 
and the third downward, the second and third being in 
the sagittal plane. At the junction of the first and second 



32 ANATOMY AND PHYSIOLOGY OF THE EAR 

portions is the geniculate ganglion, which is the origin 
of the large and small superficial petrosal nerves. These 
reach the middle fossa through an opening in the Fallopian 
canal (hiatus Fallopii). The former joins with the large 
deep petrosal to form the Vidian nerve, which is one of 
the roots of Meckel's ganglion; while the small super- 
ficial petrosal connects with the otic ganglion. These 
nerves have been considered by some as taste paths, 
carrying the centripetal impulses received through the 
chorda tympani. This has been denied by others who 
believe that the pars intermedia of Wrisberg is the taste 
path for stimuli reaching the geniculate ganglion through 
the chorda tympani. 

Chorda Tympani. — The chorda tympani is the nerve 
of taste for the anterior two-thirds of the tongue, being 
capable of responding to stimuli for the four primary 
tastes: acid, bitter, sweet, and salty. Its fibers accom- 
pany the lingual from which they separate beneath the 
ramus of the mandible, and passing backward enter a 
small canal (iter chorda anterious), the canal of Hugier, 
which runs parallel with the Glaserian fissure, and 
emerges on the anterior tympanic wall near the anterior 
margin of the Rivinian segment. The nerve then passes 
through the tympanum, being enveloped by the anterior 
and posterior folds of mucous membrane, and lying in 
the angle formed by the articulation of the malleus and 
incus. It enters the iter chorda posterious, an osseous 
canal, which extends from the posterior wall of the 
tympanum near the posterior margin of the Rivinian 
segment to the Fallopian canal at the stylomastoid 
foramen. The chorda joins the facial slightly internal 
to this foramen and its fibers accompany those of the 
facial to the geniculate ganglion. In infants that part 
of the nerve between the tympanum and the facial lies 
on the surface of the mastoid process beneath the peri- 
osteum, merely dipping beneath the upper end of the 
tympanic ring to enter the tympanic cavity. 



INNER EAR . 33 



INNER EAR. 



The best way for the student to acquire a knowledge 
of the osseous labyrinth is by dissection. The dry bone 
may be used, but if it is soaked in water for a day or so 
it will dissect much easier. The instruments used are 
engravers' tools which may be purchased at the hardware 
stores at a small expense. The forms which will be found 
most useful are diamond- and V-shaped. One may by 
these dissections not only gain a practical knowledge of 
the canals, cochlea and other parts of the temporal bone, 
but make some valuable specimens for future study. 

The labyrinth occupies a central position in the tem- 
poral bone which corresponds to the external part of the 
petrous portion. It consists of the cochlea anteriorly, 
the semicircular canals above and posteriorly, and the 
vestibule uniting these two parts. The soft structures 
lying within are enclosed by dense ivory-like bone — the 
labyrinthine capsule. From a physiological standpoint, 
the labyrinth is divided into two parts, the acoustic 
and static. The cochlea, being concerned with receiv- 
ing sonorous vibrations, is called the acoustic labyrinth. 
The semicircular canals, perhaps also the vestibule, are 
parts of the apparatlis for maintaining equilibrium and 
are therefore spoken of as the static labyrinth. 

Semicircular Canals. — The semicircular canals (Figs. 
10-13), three in number, are half-round and consist of 
a thick ivory-like cortex enclosing a small canal; the 
diameter of which is about one-twentieth of an inch, 
except at one extremity where there is an expansion form- 
ing the ampulla. This enlargement is for the accommoda- 
tion of the crista ampullae, which is a little mound of 
nerve tissue and an end-organ of one of the branches of 
the vestibular division of the eighth nerve. Each canal 
has its ampullated end and its smooth or non-ampullated 
extremity. An accurate conception of their location 
and the relative position of their ampullated ends is 
essential to an understanding of the functional tests of 



34 ANATOMY AND PHYSIOLOGY OF THE EAR 

the static labyrinth. The horizontal or external canal 
lies approximately in the horizontal plane. Its ampulla 



^ 


J 


^9 


Ki 


m0 


n§k 


^T ^ 


at^ 


^^ 


^1^ 






■^H 


k 




S?' . 






"'*^- 





Fig. 10. — Ri<^ht scmic ircular canals. From above. For rolation of 
canals to the skull compare with Fig. 14. 



HORIZONTAL 
CANAL 



SUPERIOR 
CANAL 




POSTERIOR 
CANAL 

Fig. 11.— Key-plate to Fig. 10. 



is anterior and its smooth end enters the vestibule pos- 
teriorly. Of all the canals it is the one which is most 
exposed, as its ivory-like cortex lies bare in the floor of 



INNER EAR 



35 



the antrum. The superior or supero vertical canal is, 
as its name implies, vertical. Its plane is nearly trans- 
verse to the axis of the petrous portion of the temporal 
bone. Its ampulla is in front, below and external, adja- 
cent to that of the horizontal canal. Its smooth end 
joins with the upper end of the posterior canal to form 




Fig. 12. — Left semicircular canals. External view. 



a common branch, the crus commune, which opens into 
the vestibule. Its convexity produces an eminence on 
the floor of the middle fossa, the eminentia arcuata. In 
its concavity on the cranial aspect is the subarcuate 
fossa. In the infant this is a well-marked depression 
outlining the canal, but in the fully developed bone it 
is filled to a greater or less extent with osseous tissue. 



36 ANATOMY AND PHYSIOLOGY OF THE EAR 

It nevertheless conveys a vein and a process of dura 
mater, and through it infection may reach the cranial 
cavity from the antrum. The posterior or posterior- 
vertical canal is also vertical. Its plane is nearly parallel 
with the axis of the bone. Its ampulla is at its lower 
extremity and its upper end joins with the superior canal 
to form the crus commune. Its convexity is directed 
toward the mastoid portion, and in cellular bones may 
be exposed while performing the mastoid operation. 



HORIZONTAL 
CANAL 



SUPERIOR 
CANAL 



PROMONTORY. 




OVAL 
WINDOW 



ROUND 
WINDOW 



Fig. 13.— Key-plate to Fig. 12. 



The relative position of the canals is that the plane 
in which each lies is practically perpendicular to the 
plane of the other two (Fig. 14). The axis of the tem- 
poral bone forms with the median line (approximately) 
an angle of 45 degrees, and the axes of the two bones 
make with each other an angle of about 90 degrees, or 
a right angle. As the superior canal is transverse to the 
axis of the bone and vertical, it follows that it must be 



INNER EAR 



37 



in a plane which is parallel to that of the posterior canal 
on the opposite side, since this canal is vertical and its 
plane is in the axis of the opposite bone. The horizontal 
canals on the two sides are in the same plane. 




Fig. 14. — Plane of canals and axis of temporal bone. 



Vestibule. — The vestibule is a small cavity which lies 
beneath the bone which exists between the two ends of 
the horizontal semicircular canal. It varies in size in 
different bones but the following measurements are 
correct for an average-sized cavity: '' ^ inch from above, 
downward; | inch without, inward" (Gray). It pre- 
sents the five openings for the three semicircular canals 



38 ANATOMY AND PHYSIOLOGY OF THE EAR 

— above and anteriorly, the ampullated ends of the supe- 
rior and the horizontal canals; above and posteriorly, the 
smooth end of the horizontal canal and the crus commune ; 
below and posteriorly, the ampullated extremity of the 
posterior canal. Besides these five openings are the 
foramina for the vestibular nerve situated on the inner 
wall of the vestibule. On its posterior wall is the opening 
of the aqueductus vestibuli, which is a small canal open- 
ing on the posterior surface of the petrous portion between 
the internal auditory meatus and the groove for the 
lateral sinus. In the recent state this contains the ductus 
endolymphaticus, a part of the membranous hibyrinth. 
On the external wall of the vestibule is the oval window, 
anterior and inferior to which exists the opening into the 
first turn of the cochlea, containing the canaHs reuniens 
Hensenii which unites the cochlear duct with the saccule. 
On the inner wall of the vestibule are two depressions 
separated by a crest-like process. The anterior is round 
(spherical recess) and lodges the saccule, a small mem- 
branous sac which communicates with the cochlear duct. 
The posterior is oval (elliptical recess) and contains 
the utricle, a small oval sac, which is coimected by five 
openings with the membranous semicircular canals. 
From the utricle arises a tube which, joining with a 
similar one from the saccule, forms the ductus endolym- 
phaticus which extends through the aqueductus vestibuli 
into the dura on the posterior surface of the temporal 
bone and is concerned in the regulation of the intra- 
labyrinthine pressure. 

Cochlea. — The cochlea, as its name indicates, is shaped 
like a snail shell. It is composed in the human species 
of two and one-half turns around a central stem or 
modiolus. The base of the modiolus rests upon the antero- 
inferior division of the fundus of the internal auditory 
meatus and its direction, and therefore the axis of the 
cochlea, is forward and outward. The beginning of the 
first turn of the cochlea around the modiolus forms the 
promontory on the internal tympanic wall. This may be 



INNER EAR 39 

plainly seen if the drum membrane is removed or destroyed 
by disease. The second turn lies immediately anterior 
to the first but forms no prominence. It ma}^ however, 
be easily opened by the surgeon if thought necessary. 
The third, which is only a half-turn, is buried in the mass 
of bone which forms the carotid canal. The modiolus 
is a fragile, porous pyramid through which the cochlear 
branch of the eighth nerve reaches the organ of Corti. 
Meningeal sheaths extend around these nerves into the 
modiolus so that its fracture during the labyrinth opera- 
tion may result in the escape of cerebrospinal fluid 
(Richards). Projecting into the cavity of the cochlea 
from the sides of the modiolus is a spiral process, the 
lamina spiralis, which gives passage to the terminal 
branches of the cochlear nerve. At the base of this 
lamina is a spiral canal (RosenthaPs canal), which con- 
tains a gangliaform enlargement of the cochlear nerve 
called the spiral ganglion. The lamina spiralis as well 
as Rosenthal's canal containing the spiral ganglion wind 
around the axis of the cochlea two and a half times. 
The free margin of the lamina presents two lips. To 
the one toward the base of the cochlea is attached the 
basilar membrane which extends across the cochlear 
tube and is attached to a thickened part of the periosteal 
membrane (ligamentum spiralis) lining the outer wall of 
the cochlea. The basilar membrane extends in a spiral 
manner from the base to the apex of the cochlea, and 
divides this cavity into two tubes. The one toward 
the apex is still further divided by Reisner's membrane, 
which extends from the surface of the lamina spiralis to 
the outer wall of the cochlea where it is inserted at some 
distance from the basilar membrane (Fig. 15). There 
are th^is formed three compartments or spiral tubes. 
The one toward the base of the cochlea is called the scala 
tympani, as it begins at the round window in relation 
with the tympanic cavity, from which it is separated by 
the membrana tympani secondaria. It extends from this 
location two and one-half times around the cochlear 



40 ANATOMY AND PHYSIOLOGY OF THE EAR 

axis to the apex or cupola. In this scalse near the base 
is the opening of the aqueductus cochleae by which com- 
munication is established with the meningeal cavity. 
The tube which lies toward the apex is called the scala 
vestibuli, as it begins at the vestibule and extends to the 
cupola where it joins the scala tympani, the junction 
being called the helicotrema. Lying between these two 




Fig. 15. — Transverse section of a cochlear whorl, showing formation of 
the scalse. (Gerrish.) 

tubes is the third, the scala media or cochlear duct, which 
ends in a blind extremity at the apex and at the base 
opens into the saccule by a small, short canal, the cannalis 
reuniens Hensenii. These scalse are filled with fluid; 
the cochlear duct contains endolymph, while the other 
two scalse contain perilymph. 

Organ of Corti. — Lying upon the basilar membrane in 
the scala media is the organ of Corti, which is the end- 



INNER EAR 



41 



organ of the cochlear branch of the eighth nerve (Fig. 16). 
This organ is formed as follows: There are two rows of 
supporting cells or rods, an inner (toward the cochlear 
axis) and an outer row, which join at their apices but are 
separated at their attachment to the basilar membrane, 
thus enclosing a spiral space — the tunnel of Corti. They 
support the hair cells to which terminal filaments of the 
cochlear nerve have been traced. These hair cells are 
therefore the real nerve endings of the cochlear branch 
of the eighth nerve. They are arranged as follows: one 
row internal to the rods and tunnel of Corti, and several 



Membrana tectoria. 



Outer hair cells. 



Limbus. 




Nerve fibres. 



CelU of Deiters. '"^ 

Oi/ter rod. 



Basilar membrane. 



Fig. 16. — Section through organ of Corti. (G. Retzius.) 



rows external to these structures. The external hair 
cells are still further supported by Dieters's cells, which 
rest upon the basilar membrane by expanded bases, the 
opposite ends projecting between the hair cells. External 
to the outer hair cells are the supporting cells of Henson, 
and still more externally are situated the cells of Claudius. 
The hair-like processes project from the free ends of the 
hair cells into the scala media. Stretching over these is 
the tectorial membrane. In sections of the cochlea this 
membrane appears variously displaced and distorted 
but it is probable that in the recent state its periphery 



42 ANATOMY AND PHYSIOLOGY OF THE EAR 

is attached to Corti's organ external to the outer hair 
cells, and it thus lies floating upon the ciliary processes 
of the hair cells and by its movement in vibration of the 
labyrinthine fluid is capable of stimulating these cells, 
thus producing the sensation of sound. 

Blood Supply. — The blood supply of the labyrinth is 
derived almost exclusively from the internal auditory 
artery, a branch of the basilar. This divides at the fundus 
of the internal auditory meatus into the cochlear and 
vestibular branches. The cochlear divides into small 
branches which enter the modiolus and pass through 
canals in the lamina spiralis to supply the membranous 
structures. The vestibular divides into branches which 
accompany the nerves, and supply the membranous 
structures in the semicircular canals and vestibule. 

Nerves. — The eighth nerve divides at the fundus of the 
internal auditory meatus into two parts, the cochlear 
and vestibular. The latter is posterior and has developed 
upon it an enlargement, the vestibular ganglion or gan- 
glion of Scarpa. The nerve then divides and enters the 
foramina in the posterior cribriform areas of the fundus 
of the meatus (Fig. 17). One branch passes to the crista 
of the posterior semicircular canal through the foramen 
singulare. The remaining branches are distributed to 
the saccule, utricle and also to the crista* of the horizontal 
and superior canals. In the cristse the nerve endings 
arborize around the hair cells. The cochlear nerve 
divides into numerous branches which pass through 
foramina in the antero-inferior division of the fundus 
and enter the canals in the modiolus. As they pass into 
the lamina spiralis they enter the spiral ganglion in 
Rosenthal's canal, emerging from which they pass to the 
margin of the tympanic lip of the lamina spiralis ossea 
and entering the organ of Corti are connected with the 
hair cells. 

In tracing the eighth nerve to its central connections, it 
must be remembered that it is composed of two separate 
sets of fibers — the cochlear which conduct auditory 



INNER EAR 



43 



impulses, and the vestibular which is concerned with 
maintaining equilibrium and in orientation. These 
fibers are in the same trunk form near the fundus of the 
internal auditory meatus to their entrance into the 
brain, which takes place in the groove between the pons 
and the medulla immediately anterior to the restiform 
body. From this point the two roots have separate 
connections. 




Fig. 17. — Diagrammatic ^^.ew of the fundus of the internal auditory 
meatus: i, falciform crest; 3, anterosuperior cribriform area; 2', 
internal opening of the aquaeductus Fallopii; S, vertical crest which 
separates the anterior and posterosuperior cribriform areas; 4. 
posterosuperior cribriform area, with (^0 openings for nerve filaments; 
5, antero-inferior cribriform area; 5', spirally arranged, sieve-like 
openings for the nerves to the cochlea; 5'', opening of the central canal 
of the cochlea; 6, crest which separates the anterior and postero- 
inferior cribriform areas; 7, postero-inferior cribriform area; 7', 
orifices for the branches of the nerve to the saccule; 8, Foramen singu- 
lare of Morgagni, with the anterior portion of the canal which gives 
passage to the nerve to the posterior semicircular canal. (Testut.) 



Vestibular Root. — The vestibular divides into two sets 
of fibers, one of which connects with the internal nucleus, 
which is in the floor of the fourth ventricle, while the 
other set enters the external nucleus which consists of 
two parts, an inner nucleus (Dieters's) and an outer nucleus 
(Bechterew's). From this external nucleus, possibly from 
the internal also, axones pass to the roof nuclei of the 



44 ANATOMY AND PHYSIOLOGY OF THE EAR 

opposite side of the cerebellum. Some fibers of the ves- 
tibular nerve also reach these nuclei without entering the 
external or internal nuclei. Fibers also pass forward from 
the nuclei of the vestibular nerve to end in the tegmentum, 
or to arborize around the motor oculi nuclei. Besides 
these connections fibers from the vestibular nerve pass 
to a spinal nucleus of undetermined location (Santee). 

Cochlear Root, — The fibers of the cochlear nerve enter 
either the accessory nucleus or the tuberculum acusticum. 
Axones from these nuclei pass to the superior olive, the 
trapezoid nucleus, or the lateral fillet, either of the same 
or the opposite side. From the trapezoid nucleus and the 
superior olive axones pass to the lateral fillet of the same 
or opposite side. The lateral fillet, consisting in the 
main of crossed fibers, is connected with the inferior 
quadrigeminal body both of the same and the opposite 
side. Fibers also pass to the internal geniculate bodies 
and through the acoustic radiation to the cortex of the 
temporosphenoidal lobe. 

Physiology of Audition. — Sonorous vibrations, striking 
the drum membrane, set this structure into vibration 
and its movements are transmitted through the ossicular 
chain and oval window to the perilymph in the scala 
vestibuli. In order that this fluid may vibrate, some 
other yielding place must exist in the labyrinthine wall. 
The round window which is closed by a flexible membrane 
at the base of the scala tympani, furnishes this resiliency. 
Thus sonorous impressions set the perilymph in the scala 
vestibuli and tympani in vibration. This movement is 
communicated to the flexible tube, the scala media, which 
lies between them and necessarily affects the organ of 
Corti which lies in this scala. The vibration produces 
in this organ a stimulation which is interpreted as sound. 
Of this there is no question. When it comes to consider 
in what manner these vibrations act upon Corti 's organ 
to produce the sensation of sound, one enters upon a 
subject which has given rise to much discussion. The 
organ of Corti is the structure which interprets the 



INNER EAR 45 

attribute of sound called pitch. There is no other structure 
which is at all designed to accomplish this. Pathological 
processes may result in destroying the ability to hear 
sounds of a certain pitch. Any theory to be acceptable 
must furnish an explanation of the manner in which the 
pitch is recognized, and account for the ability of a 
pathological process to destroy the pitch perception in 
a part only of the musical scale. One of the older theories 
is that of Helmholtz. He believes that the selective 
action which enables the pitch to be analyzed resides is 
the basilar membrane. The fibers of this membrane 
vary in length in a regular manner from the base to the 
apex of the cochlea, the longer being at the apex and the 
shorter at the base. He assumes that a fiber, or perhaps 
a set of fibers, vibrate in consonance with a sound of a 
certain pitch. The high-pitched sounds, which would 
presumably carry a shorter distance into the labyrinthine 
fluid, are assumed to affect the shorter fibers of the 
basilar membrane near the base of the cochlea, while 
the sounds of lower pitch which would produce vibrations 
extending farther toward the apex would cause a vibra- 
tion of the longer fibers existing in this location. This 
theory is also a suflicient explanation of the pathological 
loss of pitch perception in a part of the musical scale. 
It seems, how^ever, as though nature must have designed 
a niore direct way of stimulating the hair cells than 
through the basilar membrane, although it is conceivable 
that vibration of a cell or cells in the basilar membrane 
could produce motion in a set of hair cells, and excite 
them by the movement of their ciliary processes in contact 
with the tectorial membrane. Other theories place the 
selective action in the rods or hair cells or tectorial 
membrane. All of these theories are more or less pure 
speculation. 

Labyrinthine Pressure. — The ductus endolymphaticus 
and the aqueductus cochleae are concerned in regulating 
the pressure within the labyrinth. The ductus endo- 
lymphaticus is formed by two small tubes which arise, 



46 ANATOMY AND PHYSIOLOGY OF THE EAR 

the one from the saccule, and the other from the utricle. 
These join, forming this duct, which extends through the 
aqueductus vestibuli and forms a sac in the layers of 
the dura on the posterior surface of the temporal bone, 
between the internal auditory meatus and the lateral 
sinus. The fluid in this ductus endolymphaticus is the 
same and continuous with the endolymph within the 
membranous labyrinth. This sac being compressible and 
lying mainly within the cranial cavity, maintains the 
pressure within the membranous labyrinth at that of 
the cranial cavity. The aqueductus cochleie, while it 
does not extend within the cranial cavity, is a direct 
communication between the perilymph in the scala 
tympani and the fluid in the subdural space, as it opens 
into a meningeal process which passes into the posterior 
lacerated foramen. Colored fluid will find its way from 
the subdural space into the perilymph of the labyrinth. 
Thus the pressure, both of the endo- and perilymph, is 
maintained practically at that of the intracranial cavity. 



CHAPTER II. 
EXAMINATION OF THE PATIENT. 

HISTORY. 

Before proceeding to a special aural examination of a 
patient, his family, personal, and aural history should be 
obtained. 

Family History. — The occurrence of impaired hearing 
in his parents or several of his relatives may have an 
important bearing upon the diagnosis. It is a well-known 
fact that certain aural conditions accompanied by impair- 
ment of hearing ocour in members of predisposed families. 
Inherited syphilis may cause aural disease, and if this is 
suspected, some attempt by indirect questions, may be 
made to establish the fact that the disease has occurred 
in the parents. Usually the' patient, if this is the cause of 
his disease, will show the stigmata of this affection. 

Personal History. — In a great many instances this is 
of importance. Many of the suppurations of the middle 
ear have their inception in the infectious diseases of 
childhood — typhoid fever, pneumonia, or other general 
diseases — and this may have considerable influence on 
the prognosis. So, also, affections of the labyrinth with 
impairment of hearing may be caused by some of these 
diseases, as mumps, measles, scarlatina, etc. The occur- 
rence of syphilis, injuries to the head, attacks of dizziness, 
and many other conditions which cannot be enumerated 
in detail, all have their bearing in forming an accurate 
conception of the patient's aural condition. 

Aural History. — The aural history is not so likely to 
be neglected, but nevertheless should be obtained in a 
thoroughly systematic manner. The cardinal symptoms 
of ear disease are pain, discharge, impaired hearing. 



48 EXAMINATION OF THE PATIENT 

tinnitus, and vertigo. In ascertaining which of these are 
present, it is important to inquire as to certain character- 
istics which these symptoms may present, the significance 
of which will be developed as the diseases in which they 
occur are discussed. These characteristics are as follows: 

Pain. — The duration, intensity, and location of the pain 
are to be noted. If pain on pressure, whether it is produced 
by pressing upon the mastoid process or upon the external 
auditory canal; whether or not movement of tlie auricle 
causes pain. The character of the pain should also be 
noted, whether continuous and throbbing or intermittent, 
as in neuralgia. 

Discharge. — Concerning the discharge are to be noted 
the following points: whether profuse or scanty; contin- 
uous or intermittent; purulent, sanguinolent, or serous; 
and total time shice it appeared. 

Impaired Hearing. — Note the duration since deafness 
appeared; whether the impairment has been progressive 
and increased steadily, or intermittently during attacks 
of nasopharyngeal catarrh or ^' colds.'' 

Tinnitus. — Tinnitus is a symptom about the presence 
of which the patient seldom allows the surgeon to be in 
doubt. It should be put down in the history, but a minute 
discussion of it with the patient will not lead to any 
valuable result, as it tends to fix the patient's mind upon 
this symptom, which is to be avoided as far as possible. 
During treatment it is to be ignored as far as possible, 
for if the patient continually directs his mind to this 
symptom he will endeavor to gauge his improvement by 
the amount of tinnitus present. This alone tends to 
exaggerate the subjective noises. 

Vertigo. — This symptom when present in aural disease 
is due to some disturbance of the static labyrinth or 
vestibular nerve. Its presence or the history of previous 
attacks may be of great aid in arriving at a conclusion 
as to the aural disease of the patient. Associated with 
vertigo one very frequently finds nystagmus. This is an 
oscillation of the eyes, and may be due to many causes. 



HISTORY 



49 



Name 

Address 

Occupation 



ST. LUKE'S HOSPITAL (Out-patiext Department). 



Age 



Xatioxality 
M. S, 
W. 



Date 



Department 

Diagnosis 

Complications 

. Chief complaint 

Impaired hearing right 

Tinnitus " 

Discharge " 

Pain " 

Eyes " 

Vertigo 

Nausea vomiting 

Headache 

Paralysis 

Nose 

Pharj-nx 

Larynx 

Course 

Habits 

Past history 

Family history 

Operations 

Genl. health 

Auricle, right 

^Meatus, right 



OTOLOGICAL 



No. 



left 



left 





Mastoid 


right 






lefi 


b 




Spon. nyst. " 






" 




Tubes 






it 




Paralysis 












, R. < 

1 i A 


1 '^ 
1 R. ^ 
:Moderate 1 A 




f Upper \ 
R. \ 1 


[B 

\ ^^ 256 bone f ^' 


Watch 


S 


[ Lower \ 


1 rS 

lA 


conduc- 


acou- '. 
meter 


i f B low forced. ] i B 
L. { Whisper, i L. <! 


B ■ 


[ Upper 1 
L. < 

Lower < 


fB 


tion 1 L, 
R. 




•A 


Voice, i [A 




^B 
i A 


BC AC 

L. 


Ataxia — falls to 








BC AC 


Turning {R?tt?f«; 


= nystag. to It. for 
rt. " 






Caloric i 


• , , / Heat 
^S^t : Cold 






Left{^ 


leat 
:old 





Fig. 18. — History chart. 



50 EXAMINATION OF THE PATIENT 

As a rule, when nystagmus arises from ocular or other 
causes outside of the vestibular apparatus and cerebellum, 
the movement in each direction is rapid; while in 
nystagmus arising from disturbance of the static mechan- 
ism the movement in one direction is rapid, in the opposite 
direction slow. Many apparently normal individuals 
show a slight nystagmus in extreme lateral positions of the 
eyes. This is considered of no special significance, and is 
called physiological nystagmus. As the eyes become fixed 
it usually subsides or becomes less, while in vestibular 
nystagmus fixation seems to have no efl'ect or intensifies 
the movements. 

In taking the history, as well as in recording the results 
of the subsequent examination, a history sheet with the 
headings of the important points to be brought out is of 
great value. The one reproduced (Fig. IS) will be found to 
answer practically all requirements. 

METHOD OF EXAMINATION. 

Illumination. — Probably the best light for aural examina- 
tion is the incandescent electric candle, the film being 
either of carbon or tungsten. The globe may be frosted 
if desired, and with or without a fenestra. A reflector 
and condensor may be used, but possess no advantage 
over the plain candle. The light may be attached to a 
stand with a flexible neck and extensible tube to vary 
the height (Fig. 19). With this apparatus the light may 
be placed in any desired position, or the same result may 
be attained by mounting it upon a wall bracket. An 
Argand gas burner attached to the wall by a bracket 
moving in any direction gives very satisfactory illumina- 
tion. A condensor and reflector may be used if desired. 
In emergencies outside of the office one may use an 
ordinary coal oil lamp with Argand burner, or even a 
candle when other sources of illumination are unavailable. 
If the examiner is accustomed to the electric light and uses 
some of the other forms of illumination he should make 



METHOD OF EXAMINATION 



51 



proper allowance for the resulting change in color of the 
parts, as they will not appear so white. Numerous forms 
of apparatus have been devised, in which the electric 
candle is worn on the examiner's head, the current being 
obtained from a battery or from the regular house current. 




Fig. 19. — Electric light stand. 



The light from these is very useful in operations, but they 
do not give that definition which is essential to obtain 
a satisfactory view of the membrana tympani. 

Mirror. — In selecting a forehead mirror certain points 
should be borne in mind. Three to three and one-half 
inches is the proper diameter. A larger one is more 



52 EXAMINATION OF THE PATIENT 

difficult to manage and tiresome to wear arid presents no 
points of advantage. The central aperture should be 
from one-half to five-eighths inch in diameter. Pro- 
ficiency in the use of the mirror, if one with a small opening 
is used, can only be acquired after much pains and time, 
and even then it will be found much less convenient for 
every-day work. The ball should be attached to the 
periphery of the frame (Fig. 20), thus allowing much more 
freedom of motion than if attached to the back. The 
mirror is connected with the headband bv a double ball- 




FiG. 20. — Forehead mirror. 

and-socket joint. If some object, for instance the window, 
is picked up by the reflecting surface of the mirror it 
should produce a clear, well-defined image of the same, 
showing accuracy of curvature. This ought to be about 
nine inches from the mirror, as this length of focus 
has been found to be the best. To use the forehead 
mirror it is necessary to train the muscles of the neck and 
body, so that whatever movements are executed by the 
hands the head remains fixed and the parts under observa- 
tion continue illuminated. To obtain this training rapidly 



METHOD OF EXAMINATION 53 

the following procedure is advised: With the mirror in 
position, let the student pick up the light and focus it 
upon the wall, taking care that the illuminated area is 
seen through the aperture by the eye behind the mirror. 
Then let him make as extensive movements as possible 
with his hands and arms, at the same time holding the 
light fixed in the original position. By perseverance in 
this exercise the student will soon overcome his difficulty 
with the illumination. The light should be on the 
examiner's left and so placed that the head and face of the 
patient on the side to be examined just fall in shadow. 



Fig. 21. — Aural specula. (Boucherons.) 

Introducing the Speculum, — Before introducing the 
speculum the condition of the auricle and the size of the 
meatus is noted. If the meatus is contracted or manip- 
ulation of the auricle is painful, extraordinary care in 
introducing the speculum must be taken or pain will be 
produced. The ordinary bell-shaped speculum is recom- 
mended (Fig. 21). They come in nests containing four 
sizes. Choose the largest size that can be introduced 
without using the slightest force. This is inserted into 
the meatus and the parts inspected. 

Meatus. — Three points are to be noted about the 
external auditory canal, its color, caHber, and contents. 



54 EXAMINATION OF THE PATIENT 

Color, — The normal color of the canal wall is about the 
same as that of the skin. One may find localized areas of 
reddening in circumscribed inflammation or diffuse, as in 
eczema and diffuse otitis externa. 

Caliber, — The caliber of the entrance of the meatus has 
already been noted before introducing the speculum, 
but now the deeper part of the canal is to be investigated. 
Whether it is narrow at the fundus, as in mastoiditis, or 
in the soft part of the canal, as in furuncle. 

Whether the thickening of the walls is general, as in 
diffuse otitis externa, or limited to the superior or posterior 
wall, as when pus has dissected its way out, beneath the 
periosteum, through the Rivinian segment. The con- 
sistence of the thickening should be determined; whether 
it is hard, as in exostoses, or less firm, as in the majority 
of other processes which diminish the caUber of the canal. 

Contents. — The contents may be fluid or solid, of any 
consistence between these extremes, or the canal may be 
empty. Pus may be thin and watery, of creamy con- 
sistence, or dried into hard scales on the canal walls. 
Any crust should be looked upon with suspicion which is 
found near the drum membrane, especially upon the 
superior wall, as it may be dried pus concealing a per- 
foration which leads into the tympanic vault. All of the 
characteristics of the pus are to be noted as it is removed 
with the cotton-wrapped applicator: its consistency, 
amount, color, and odor. It may be necessary in nervous 
children to remove it with the syringe before a view of the 
fundus can be obtained. Sometimes the discharge is 
sanguinolent, a condition which may exist with polypus, 
granulations, hemorrhagic otitis externa or following 
traumatism. Nor can one be satisfied in many instances 
until the aural pus is submitted to a microscopical examina- 
tion of the smear or culture. In taking the pus for a 
smear or culture, it is important to secure it fresh from 
the middle ear. In order to do this the canal is first wiped 
dry. Then the ear is inflated by Valsalva's method if 
possible, if not, with the catheter. This forces pus from 



METHOD OF. EXAMINATION 55 

the middle ear into the canal and it is taken on an appli- 
cator. If a smear is to be made, this is thinly spread on 
cover-glasses and the film fixed by rapidly passing them 
through a flame. They are then stained and examined. 
If a culture is desired, the sterile applicator is used and 
the pus is placed on slants of the proper culture media. 
Cerumen is usually found in small amount and of soft 
consistency in the external part of the canal, but often it 
will be found occluding the canal lumen. This is to be 
removed and the examination continued. The canal may 
contain foreign bodies. Those most frequently found 
when the patient is ignorant of their presence are wads of 
cotton which he has inserted at some previous time under 
the mistaken notion that they were some protection to his 




Fig. 22. — Angular forceps. 

ears. For removing these, as well as epithelial scales, 
masses of fungi, etc., the angular forceps (Fig. 22) are of 
value. 

Membrana Tympani. — Having cleared the canal of its 
contents, if any were present, the deeper parts are to be 
inspected. In order to obtain a good view of the fundus, 
one anatomical point must be borne in mind. The external 
auditory canal consists of two parts; the outer cartilag- 
inous portion is movable and has a direction upward, 
backward, and inw^ard; the inner or bony portion is non- 
movable, with a direction downward, forward, and inward. 
By traction upon the auricle in a direction upward and 
backward, these parts are brought into the same line and 
a view of the membrana tympani obtained. In young 
children the canal is straightened by drawing the auricle 



56 EXAMINATION OF THE PATIENT 

backward and downward. If the student experiences 
difficulty in locating the drum membrane, it is a good plan 
to follow with the eye one wall of the canal to and across 
the fundus and back to the speculum on the opposite 
wall. In this procedure one necessarily passes over the 
drum membrane if it is present. The different points to be 
noted are: (1) short process of the malleus; (2) handle of 
the malleus; (3) Shrapnell's membrane; (4) membrana 
tetisa; (5) cone of light; (6) anterior and posterior folds 
(Fig. 23). The hammer handle (2) or manubrium will 
be seen as a yellow streak extending from about the 
centre of the tympanic membrane in an upward direction 




Fig. 23. — Diagram of left memlirana tympani: 1, short process of the 
malleus; 2, manubrium or handle of the malleus; 3, Shrapnell's membrane, 
or membrana flaccida; Jf, membrana tensa; 5, cone of light; 6, anterior 
and (6'') posterior folds. 

and ending in a small spike-like process, the processus 
brevis or short process of the malleus (1). Extending 
from this in either direction are the anterior and posterior 
folds (6). These correspond, in position, more or less 
closely to the folds of mucous membrane in the tympanum 
already described, and divide the membrane into two 
parts; the upper being Shrapnell's membrane, or mem- 
brana flaccida, and the lower, the membrana tensa. 
Shrapnell's membrane is of great importance since it 
is the only part of the wall of the vault, or upper part of 
the tympanic cavity, which can be directly inspected. It 
has in the normal state about the appearance of skin. 
It is of a delicate pink color, without luster as compared 



METHOD OF EXAMINATION 



57 



with the membrana tensa. It is continuous with and of the 
same appearance as the superior canal wall. Owing to 
the obliquity of the anterior and posterior folds, and since 
it fills in the segment of a circle, the vertical measurement 
of ShrapnelFs membrane is greatest from the short process 
upward, diminishing to its anterior and posterior extremi- 
ties which lie at the ends of the tympanic ring. Normally, 
it is slightly concave. It should be carefully examined 
for perforations, bulging or redness, although the color 
may vary considerably without pathological significance. 
Quadrants of the Membrana Tensa. — For convenience of 
description, the membrana tensa is divided into quadrants 




Fig. 24. — Diagram of the quadrants of the tympanic membrane: 

1, posterosuperior of hearing quadrant overlying incus (5) and stapes (6) ; 

2, postero-inferior quadrant over niche of round window (<^) ; outHne 
of promontory (7); 3, antero-inferior quadrant; ^, anterosuperior quad- 
rant; tympanic opening of canal for tensor tympani (9) and Eustachian 
tube (10). 

by imaginary lines (Fig. 24) ; one extending from the tip 
of the manubrium to the floor, and another at a right 
angle to this at the tip of the manubrium or umbo, the 
hammer handle completing the division. A knowledge of 
the tympanic structures which underlie these quadrants 
is essential. The posterosuperior quadrant lies over the 
oval window containing the stapes articulated with the 
long process of the incus. For this reason it is sometimes 
spoken of as the hearing quadrant. These structures 
may not infrequently be seen when the membrana tensa 
is destroyed, or for any reason is thin and transparent. 
At the posterior margin of the postero-inferior quadrant 



58 EXAMINATION OF THE PATIENT 

is the niche of the round window, the margin of which 
may sometimes be seen when the tympanic membrane is 
absent. The parts of the posterior quadrants toward the 
umbo or end of the manubrium overHe the promontory. 
In this location the drum membrane approaches nearer 
to the internal tympanic wall than at any other place, 
in a normal tympanum these structures being about one- 
twelfth inch apart. Opposite the anterior quadrants the 
internal tympanic wall is receding until near the tympanic 
ring it attains its maximum distance from the membrane, 
which is about one-fifth of an inch. There is, however, 
considerable variation in both of the measurements, 
above given, in the tympani of different subjects. At the 
margin of the anterior segments and at a slightly deeper 
level is the tympanic opening of the Eustachian tube, and 
above it the opening of the canal for the tensor tympani 
muscle. In the recent state the canal is occupied by this 
muscle, and its tendon crosses the tympanum to its attach- 
ment to the manubrium. Of the membrana tensa (Fig. 
23, 4) there is to be noted the color, luster, position, 
integrity, and structure. 

Color. — The only way the student can form an accurate 
conception of the normal color and luster of the tympanic 
membrane is by making repeated examinations of normal 
ears. This he should do so that he may be quick to per- 
ceive an abnormal condition when it presents. The 
normal color of the drum membrane is a grayish tint, but 
it varies considerably within physiological limits. If the 
membrane is very thin the color of the mucous membrane 
on the internal tympanic wall may show through. This 
pink color must not be attributed to the drum head to 
which it does not belong. The tympanic membrane 
becomes of varying degrees of redness in inflammatory 
diseases of the middle ear. Care should be taken not to 
misinterpret the physiological redness along the hammer 
handle and around the circumference of the drum mem- 
brane. This is due to injection of the manubrial and 
peripheral plexuses, and frequently occurs after prolonged 



METHOD OF EXAMINATION 59 

examination with the speciihim inserted or after removal 
of the cerumen and is without special clinical significance. 

Luster. — The normal luster is a quality in itself. It is a 
peculiar sheen not very unlike mother of pearl, and is due 
to the character of the epithelium which covers the drum 
membrane. ^Yhen for any reason this becomes necrotic 
or exfoliates en masse, the drum head becomes lusterless. 
This may occiu- in certain forms of otitis externa, but 
is a much more important indication of acute purulent 
otitis media, and in this condition the membrane at times 
very much resembles wet blotting paper. Besides this 
total loss of luster, varying degrees of its diminution may 
be present. Care should be taken not to confuse the 
cone of light with luster. This may be absent, as it is in 
many instances in perfectly good ears, and the drum 
membrane be of normal luster. The light reflex is caused 
by the concavity of the anterior part of the membrane 
which allows rays of light to strike the area of the reflex 
perpendicularly and be reflected back to the eye. The 
normal obliquity of the membrane is such that rays 
of light from the forehead mirror are reflected downward, 
forward and outward, to the anterior wall of the canal. 
Contraction of the tensor tympani depresses the manu- 
brium and consequently the drum head along this process, 
the depression being greatest near the umbo or end of the 
manubrium. This increases the obliquity of the upper 
and posterior part of the membranes and diminishes that 
of the lower and anterior part. Thus an area is formed 
which is nearly perpendicular to the axis of the canal, 
striking which the rays of light from the mirror are 
reflected back to the eye. So while a good luster must be 
present in order to produce a well-developed cone of light, 
its absence does not, in itself, indicate a loss of luster. 
A well-formed light reflex begins at the umbo and spreads 
out in a triangular form to near the anterior and inferior 
margin of the tympanic ring. 

Position. — If the depression of the drum membrane 
becomes extreme the light reflex recedes from the umbo 



60 EXAMINATION OF THE PATIENT 

and loses its cone-like shape. In forming an opinion as 
to the amount of depression of the drum membrane much 
more reliance should be placed upon other indications. 
These are: (1) Foreshortening, of the manubrium; as 
this structure is viewed more obliquely it appears shorter; 
(2) prominence of the posterior fold; (3) prominence of 
the tympanic ring; (4) apparent narrowing of the posterior 
part of the membrane. Bulging is usually quite easily 
made out. The appearances which exist are as follows: 

(1) broadening of the posterior segments of the membrane; 

(2) apparent lengthening of the manubrium, which at 
times seems to lie in a gutter; (3) the posterior fold is 
more or less obliterated; (4) the tympanic ring is less 
prominent and may even appear depressed. 

Integrity. — Some perforations are readily made out. 
If difficulty is experienced auto-inflation or catheteriza- 
tion may aid one. The pus is wiped away so that a good 
view of the tympanic membrane is afforded then inflation 
is performed (usually by the patient) and the location 
at which pus first appears is noted; this of course will 
be the site of the perforation. It may be impossible to 
force the contents of the middle ear through the perfora- 
tion either by auto-inflation or by catheterization. This 
may occur in posterior perforations where the anterior part 
of the cavity is closed oft* by adhesions or the cicatricial 
drum membrane is adherent to the promontory; or in 
perforations in Shrapnell's membrane, where, as may be 
the case, the vault is separated from the lower part of the 
tympanic cavity by the thickened folds of the mucous 
membrane. In this event a SiegeFs otoscope may be of 
value (Fig. 25). This instrument is so constructed that 
the air pressure may be increased or diminished in the 
external meatus, the examiner in the meantime having a 
view of the fundus of the canal. By producing a minus 
pressure any secretion which may be in the tympanum 
will be drawn out. By alternately condensing and rare- 
fying the air in the meatus a very good idea of the amount 
of motilitv of the drum membrane mav be obtained. 



METHOD OF EXAMIXATIOX 61 

Inflation of the middle ear when a perforation is present 
may also give a certain amount of information as to the 
size of the opening. After the tympanic contents are forced 
out and air comes through, the pitch of the perforation 
sound will be high in small openings and low in larger 
perforations. To a certain extent the size of the perfora- 
tion is an indication as to whether or not drainage is good. 
With a high-pitched whistle showing a small perforation, 
drainage is presumably insufficient, while with a low- 
pitched sound produced by a large perforation, drainage, 
at least as far as the membrana tympani is concerned, 
may be considered satisfactory. In total absence of the 
membrana tympani, the internal tympanic wall may be 




Fig. 25. — Siegel's otoscope. 

mistaken for a red bulging drum membrane. Tracing 
along the wall of the canal to and over the fundus, will 
frequently enable one to avoid this error. It will be found 
that as one's vision passes over the tympanic ring to 
the internal tympanic wall, a well-marked offset exists. 
Inflation and the use of the probe are also suggested in 
case difficulty in identifying the nature of the structure 
is experienced. 

Structure. — The thickness and translucency of the 
membrana tensa varies greatly. Some membranes are 
nearly transparent and allow the stapes and long process 
of the incus to be seen and the pink color of the mucous 
membrane on the internal tympanic wall to show through. 



62 EXAMINATION OF THE PATIENT 

Others are nearly or quite opaque. Thin atrophied mem- 
branes are at times associated with chronic catarrhal 
processes. Opacity of the drum head may be due to the 
deposit of lime salts or to thickening the result of acute 
or chronic purulent inflammation of the middle ear. 

It is a good plan to examine the opposite ear before 
the involved one, as a comparison can then be made. In 
any event it should always be examined. The condition 
of the nose apd nasopharynx should also be investigated 
as a matter of routine. 



INFLATION OF THE MIDDLE EAR. 

Inflation of the middle ear is at times a part of the 
examination, at others it is a therapeutic procedure. 
It consists in forcing air under pressure into the middle 
ear and may be accomplished in three ways: by \'alsalva's 
method, by Politzer's method or by catheterization. 

Valsalva's Method. — In this method the inflation is 
performed by the patient. It is therefore frequently 
spoken of as auto-inflation. The patient closes the nose 
by the thumb and finger so that no air can escape, and 
at the same time endeavors to force air through the 
nose. This produces a positive pressure in the naso- 
pharynx and the air is forced through the Eustachian 
tube into the middle ear. Valsalva's method may be used 
to assist in finding a perforation of the drum membrane, 
and to give information as to the amount of drainage in 
middle-ear suppuration. If the air blows through the 
ear freely, one may estimate the degree of drainage present. 
If it is not forced through at all, no evidence as to the 
drainage is furnished, as the force exerted in this manner 
may be insuflScient to overcome the resistance offered 
by a swollen or contracted tube. For all other purposes 
Valsalva's method is to be condemned. 

Politzerization. — In Politzerization the positive pressure 
in the nasopharynx is produced by compressing a rubber 



INFLATION OF THE MIDDLE EAR 63 

bulb which is connected by a tube with a tip of proper 
size and shape to occlude one nostril, the other being 
closed by the operator. The nasopharynx is closed off 
below by the elevation of the soft palate until it comes in 
contact with the posterior wall of the pharynx. This is 
accomplished by having the patient take a swallow of 
water, utter the sound represented by *' K,'' or by perform- 
ing the act of blowing with the mouth closed. As the sound 
is uttered, or the patient swallows, the bulb is compressed 
and the air enters the tympanum through the Eustachian 
tube. If the auscultation tube is used, a sound will be 
heard as the tympanum fills with air. This procedure 
may be used in children who will not submit to catheteri- 
zation, or in adults if for any reason it is impossible or 
seems inadvisable to catheterize them. It is much in- 
ferior to this latter procedure both in its therapeutic effect 
and the information as to the state of the tube and middle 
ear which it affords. 

Catheterization. — Instruments. — ^The instruments needed 
for catheterization are an auscultation tube, catheters, 
and an inflating bag with its connections. The auculta- 
tion tube is two and one-half to three feet in length and 
one-fourth inch in diameter. Ordinary red rubber is the 
best material. The pure gum black-rubber tubes are too 
elastic and for this reason do not give one as good a sound 
as the less resilient tube. The white or operator's tip 
should be large enough to plug the canal tightly, and the 
patient's, or black one, should not be too small, as upon 
the formation of an air-tight connection between the 
meatus of the operator and that of the patient the proper 
appreciation of the inflation sound depends. The most 
useful catheter is a No. 2, although for exceptional cases 
either a No. 1 or a No. 3 will afford better results (Fig. 26). 
The total length of the catheter is six inches. If a longer 
one is used, it will interfere with the delicacy of the manipu- 
lation; if a shorter one, it will not reach to the Eustachian 
orifice in some patients. The material may be German 
silver, nickel-plated or coin silver. The latter has the 



64 EXAMINATION OF THE PATIENT 

advantage that the curve may be more easily changed to 
suit individual requirements. The tip may be either 
plain or slightly bulbous. The ring shows the direction 
of the tip, and is of use while holding the catheter in 
position during compression of the bulb. The Dench 
bag and apparatus is advised (Fig. 27). This consists 
of a rubber bulb, a hard-rubber bottle, and a tube about 
two feet long connecting with the catheter by a hard- 



^ 



'**^™** ' ■-!- ■fcif^ - ■■ V ■'"fcil, j 



Fig. 26. — Eustachian catheter. 



rubber tip. In selecting the bulb one is to be chosen that 
does not leak at the valve and fills quickly. The bottle 
is so constructed that the air forced through the catheter 
may be impregnated with vapor if desired. If the rubber 
tube connecting the bottle with the catheter is very elastic, 
too much force will be lost in transmission, if at all rigid 
it interferes with the delicacy of manipulation in passing 
the catheter. 




Fig. 27. — Dench inflating apparatus. 

Anatomy, — Some anatomical points must be constantly 
borne in mind during the passage of the catheter. The 
pharyngeal orifice of the Eustachian tube, into which it 
will be necessary to insert the catheter, is on the outer 
wall of the nasopharynx slightly above the plane of the 
hard palate. There is considerable variation in the loca- 
tion of this orifice. Judging from experience in passing 
the catheter, the usual position seems to be a little less 



INFLATION OF THE MIDDLE EAR 65 

than one-half inch anterior to the posterior wall of the 
nasopharynx, and about one-fourth inch above the plane 
of the floor of the nose. The posterior lip of the tubal 
orifice is cartilaginous and is an important guide in 
inserting the catheter. It varies greatly in prominence 
in different subjects. The tube passes in a direction 
outward, upward, and backward. Before attempting to 
pass the catheter the student should examine the nose, 
especially noting: the roominess of the inferior meatus; 
the prominence and position of the inferior turbinate ; the 
presence of spurs or deflections of the septum. He will 
then be able to determine what modification of the 
procedure may be necessary to insure success. 

Anesthesia. — Anesthesia of the mucous membrane of the 
inferior meatus and tubal orifice is advisable, especially 
in the first inflations attempted by the student. Spraying 
the nose with a 4 per cent, solution of cocain, or some 
other anesthetic, then with a cotton-wrapped applicator 
swabbing the tubal orifice with some anesthetic solution 
will properly benumb the route over which the catheter 
is to be passed. If the applicator is bent at the end to a 
curve resembling that of the catheter, it may be passed 
in the same manner as the catheter, directly into the tubal 
orifice. That it is in this position may be determined by 
the fact that a semi-fixed sensation is communicated 
to the hand. In this way a certain amount of information 
as to the location of the tube w411 be obtained that may 
be of value. 

Passing the Catheter. — The patient sits facing the 
operator with the chin well down toward the chest. This 
enables one to pass the catheter through the lower meatus 
with more certainty and ease. The fingers of the left 
hand rest upon the bridge of the nose, while with the tip 
of the thumb the end of the nose is tilted sharply upward. 
The thumb must not interfere with the lumen of the 
nostril. If these directions are not observed, the internal 
end of the catheter is in danger, either of entering the 
middle meatus, thereby causing pain and failure, or of 
5 



66 



EXAMINATION OF THE PATIENT 



reaching the nasopharynx so high that when rotated 
into position it fails to enter the orifice of the tube. At 
first the student will do well to let the patient hold the 
bottle or bag until the catheter is in position. The catheter 
is to be attached to the tip in such a manner that when 
the rubber tube is at rest, the ring will point toward the 
ear to be inflated. If the connecting tube is twisted 




Fig. 28. — First step of introduction of the catheter. Tip of the nose 
held up, the right hand depressed. The point of the catheter has entered 
the vestibule and the direction and extent of the movement of the right 
hand now taking place is indicated by the arrow. 



while search is being made for the tubal orifice, the 
resistance communicated to the fingers will be sufficient 
to mask the sensation which ought to be perceived when 
the tip of the catheter comes in contact with the posterior 
lip of the tubal orifice. The catheter or the tubing near 
it is lightly grasped by the thumb and fingers of the right 
hand exactly like a pen. If grasped firmly, pain will be 



INFLATION OF THE MIDDLE EAR 67 

caused during the passage of the catheter and faihire is 
almost certain. The tip end of the catheter is now to be 
inserted into the nose, point downward, with the right 
hand depressed (Fig. 28). As the tip passes the vestibule, 
the right hand is raised until the shaft of the catheter 
comes nearly in contact with the tip of the nose which is 
still held up by the thumb of the left hand. It is now 
passed through the lower meatus with tip of the catheter in 
contact with the floor of the nose. Absolutely no force 
is to be used in this part of the procedure. If necessary 
for it to pass freely the catheter may be allowed to rotate. 
As soon as the tip of the catheter lightly touches the pos- 
terior pharyngeal wall it is allowed to rotate, the elasticity 
of tjie rubber tube accomplishing this. The ring of the 
catheter and therefore the tip now point externally. As 
this rotation is taking place the catheter is slightly with- 
drawn and the external end pressed against the septum. 
This combined movement results in bringing the tip of 
the catheter in contact with the external pharyngeal 
wall posterior to the tubal orifice, either at the posterior 
lip of the tube or slightly behind this point. With this 
contact maintained by gentle pressure against the septum 
with the outer end of the catheter, it is now drawn for- 
ward over the posterior lip into the tubal orifice (Fig. 29). 
That it is in position here will be recognized by a semi- 
fixed feeling communicated to the right hand. The ring 
of the catheter should point in the direction of the ear 
to be inflated. The left hand now grasps the catheter, 
the ring lying between the thumb below and the forefinger 
above, the other fingers still maintaining their rest upon 
the bridge of the nose. The right hand thus freed com- 
presses the bulb and if all has gone well the operator will 
perceive by the sound heard through the auscultation 
tube that he has succeeded (Fig. 30). If he has not, no 
attempt should be made to search for the tube with the 
left hand, but the hands are to be replaced and with the 
catheter in the fingers of the right hand search made for 
the location which gives the sensation of semifixation. 



68 



EXAMINATION OF THE PATIENT 




Fig. 29. — The point of the catheter has passed through the lower 
meatus and is now in the region of the tube for which search is being 
made. 




Fig. 30. — Catheter in the tubal orifice, held in place by the left hand 
while the bag is being compressed by the right hand. 



INFLATION OF THE MIDDLE EAR 69 

Causes of Failure. — The causes of failure are generally 
that the above rules have not been carried out exactly 
or that the hand and fingers are not sufficiently educated 
to interpret the sensations communicated to them. This 
skill will come with practice but the directions above 
given must be thoroughly understood before attempting 
catheterization. At times failure results from anatomical 
conditions. If the lower turbinate is very large and the 
nose is roomy the curve of the catheter may be increased 
to enable the tip of the catheter to reach the Eustachian 
orifice. If the nose is narrow and the turbinate prominent, 
a very short curve may be used and the catheter passed 
outside of the turbinate, the tip of the catheter traveling 
along the external and superior angle (naso-antral wall) 
of the inferior meatus. It is introduced by sight external 
to the lower turbinate and passed backward until it 
meets with the anterior surface of the posterior lip of the 
tube, when it will be found to be in the tubal orifice. 
This same method may be tried if the septum is so promi- 
nent that it is impossible to pass the catheter between 
it and the lower turbinate. In some deflections bending 
the catheter to conform to the septal deformity will 
enable one to succeed. With an anterior deflection with 
but little room an instrument with very small curve may 
be passed and success achieved. If the deflection of the 
septum is so extreme that the catheter cannot be passed 
by any of these maneuvers, either the deformity must 
be corrected by operation or the opposite side used for 
the passage of the catheter. This is possible in a great 
many patients but cannot be regarded as a satisfactory 
procedure. An instrument of large curve is used and the 
posterior border of the septum taken as a guide, the 
Eustachian orifice being about opposite to this landmark; 
or the catheter may be introduced into the orifice of the 
tube corresponding to the open side of the nose, then, 
without changing its depth, rotated to the opposite side, 
when it will generally enter the tubal orifice. 



70 EXAMINATION OF THE PATIENT 

Other Methods. — Another method of passing the catheter 
is advocated by some authors. The instrument is passed 
into the nasopharynx as above described, then the point 
is rotated to the side opposite to the one which it is pro- 
posed to catheterize. It is then withdrawn until the 
curve of the catheter comes in contact with the posterior 
border of the septum. The point of the instrument is 
now made to describe a semicircle, the convexity of which 
is downward. This movement brings the tip of the 
catheter into the pharyngeal orifice of the tube which 
it is desired to catheterize. This method requires much 
more manipulation of the instrument and the point of the 
catheter irritates the structures in the nasopharynx 
and often leads to troublesome retching, so that the 
catheter is firmly held by the contraction of the palatal 
muscles and its insertion, or even its withdrawal, may be 
impossible until this contraction subsides. This rarely 
occurs in the first method which has been described in 
detail, and which is very much superior to the one in which 
the posterior margin of the septum is taken as a guide. 
By using the posterior lip of the orifice of the tube as a 
guide, and following closely the directions given above, 
the student will not only be able as readily to learn to 
inflate as by any other method, but he will also lay the 
foundation for the acquisition of great skill in the use of 
the catheter. 

Interpretation of Sounds, — All sounds of intratympanic 
origin are heard through the auscultation tube as though 
arising in one's own ear. All sounds which seem to come 
from outside the examiner's ear are either tubal or 
produced at the mouth of the tube. The sound usually 
first heard is due to the vibration of the drum membrane, 
and is more or less pronounced as the membrane is tense 
or flaccid, varying from a slight thud to a sharp snap or 
click. Then follows the murmur caused by air rushing 
through the tympanum. The pitch of this murmur varies 
with the patency of the Eustachian tube. The narrower 
the tube, the higher the pitch and vice versa. Fluid in 



INFLATION OF THE MIDDLE EAR 71 

the middle ear produces either crackling or bubbling 
sounds. If there is a perforation in the drum membrane 
of small size there will be a whistle; if of large size the 
operator will feel the air blowing in his own ear. Sounds 
produced at the mouth of the tube are at times very 
annoying to the inflator, and are generally caused by the 
vibration of the mucous membrane; either because it is 
relaxed and flabby or because the catheter is not directed 
in the axis of the tube. One may usually get rid of them 
by rotating the catheter slightly, by gentle traction or 
pressure; or a catheter of different curve may be tried. 
These procedures are intended to eliminate the little fold 
of mucous membrane, vibration of which causes the noise, 
and they may also be adopted to produce a direct blast 
of air through the tube into the middle ear, when for any 
reason the one which is passing is not satisfactory. 

Accidents of Catheterization. — Catheterization may be 
considered as a very safe procedure. Very rarely an 
emphysema is produced by entrance of air through an 
injury caused by the end of the catheter or a rupture 
of the mucous membrane lining the tube. As this sub- 
mucous emphysema occurs the patient suddenly becomes 
extremely anxious and the operator may have noticed a 
puffiness of the check or neck. He must desist at once 
and not attempt another catheterization for several days. 
If one examines the throat in these patients the uvula 
and soft palate will be found swollen from emphysematous 
infiltration. The accident is free from danger if the hand 
bulb is used, but with compressed air with continuous 
flow the emphysema may extend to the glottis, causing 
distressing dyspnea. The condition heals without treat- 
ment. If compressed air has been used and dyspnea is 
present, a rapid tracheotomy would be indicated. These 
severe types are so rare that but a few cases are on record. 
Another accident which may occur is rupture of the mem- 
brana tympani. This usually occurs in cicatricial mem- 
branes and is quite startling to the operator as well as to the 
patient on account of the pop which is heard by both. 



72 EXAMINATION OF THE PATltJNT 

This accident is by no means common and may be unavoid- 
able, but in a certain type of case it may be prevented, as 
one has timely warning. The operator hears one inflation 
sound, but upon further compression of the bulb no sound 
is produced. If he will stop now and examine the mem- 
brana tympani, he will find it markedly bulging. If he 
persists in trying to obtain another inflation sound, the 
membrane will rupture. The explanation is that the tube 
is so narrow that the air cannot escape after the tympanum 
is filled, so, as more air is forced in, no further sound is 
produced but the membrane ruptures. These perforations 
usually heal without treatment and with no noticeable 
loss of function. 

FUNCTIONAL TESTS OF AUDITION. 

In testing the acoustic function of the ear, two kinds of 
tests are made use of: (1) those which furnish data as to 
the degree of impairment of hearing; (2) those showing 
the kind of impairment. The first are designed to ascertain 
and enable one to keep a record of the amount of deafness; 
while the second indicate with more or less accuracy the 
location of thie lesion causing the impairment of hearing. 
The amount of deafness is usually determined by the watch 
or acumeter, and the human voice either in the form of a 
whisper or a spoken voice. For ascertaining the kind of 
deafness, the upper and lower tone limits are determined 
and certain tests made with tuning-forks. 

Watch. — The distance at w^hich the watch is heard by 
the ear being examined is ascertained and set down while 
beneath it is placed the distance at which the watch is 
heard by the normal ear. For example: R. E.: watch, 
YQ^, denotes that a watch is heard at five inches, which the 
normal ear hears at twenty inches. There is so much 
variation in the loudness of watches that simply to mate 
that a patient hears the watch at a certain distance 
conveys no accurate impression of the amount of hearing 
which he possesses; so the number under the line is 



FUNCTIONAL TESTS OF AUDITION 73 

added to denote the distance at which the normal ear 
hears the watch used in the test, thus indic£|,ting the loud- 
ness of that particular watch. The symbol is not in any 
way to be considered as a fraction which represents the 
hearing power. A patient whose hearing for the watch 
is expressed as ^o^ has not lost three-fourths of his hearing 
any more than one who cannot hear the watch, written 
^, is totally deaf. When the watch is heard on contact 
it is written ^. If these considerations are borne in mind, 
the formula in the form of a fraction is useful in recording 
the amount of hearing for the watch. 



Fig. 31. — Politzer's acumeter. 

Acumeter. — ^When the watch cannot be heard, Politzer's 
acumeter may be used (Fig. 31). The sound, from this 
instrument, is produced by the hammer striking the metal 
cylinder, as it falls after being raised by the finger. This 
produces a clicking sound of high pitch which is heard 
by the normal ear under favorable conditions at a distance 
of 45 feet. In using this instrument care must be taken 
that the hammer falls with its own weight only, after 
being raised by pressure on its short arm, for if it is caused 
to strike with force, a louder sound will be produced and 
the test be inaccurate. In testing the hearing with this 
instrument it is started outside the range of audition and 
gradually brought nearer until the patient hears it. The 
distance in feet at which this occurs may be set down above 



74 EXAMINATION OF THE PATIENT 

the line with 45 below as in the watch test, or merely 
noted in feet or inches, as the case may be. Both the 
watch and the acumeter produce a high-pitched sound of 
peculiar quality, which it is not very important for the 
ordinary person to hear. The impairment of hearing 
which leads most patients to seek advice is their inability 
to hear the human voice; so this becomes a much more 
important means of testing the hearing power. Some 
patients will hear the watch and acumeter much better 
than the voice; others again will hear the voice much 
better than these instruments. The watch is valuable 
in detecting slight degrees of impairment in patients in 
whom no noticeable deafness for the whisper or voice is 
present. 

Whisper. — In using the whisper to determine the acute- 
ness of hearing, its loudness must be taken into considera- 
tion. It is customary to employ three degrees of intensity 
in the whispered voice: the low, the moderate, and the 
forced whisper. The low and the forced whisper have 
the least variation in their degree of loudness. The 
numbers from 20 to lOO are usually spoken and are the 
best, as they do not allow the patient to guess at any 
part of what is spoken, as he is able to do when he hears 
a sentence. For this reason, the examiner should not 
allow himself to use a regular sequence of numbers, as 
deaf patients are very keen in anticipating the ones to be 
spoken if this is done. The patient closes the opposite 
ear with the moistened finger and must not be permitted 
to see the speaker's lips. As the examiner moves away 
he comes to a place where it is evident that the patient 
hears the sound but cannot distinguish the numbers. The 
distance at which this occurs is usually put down as the 
hearing distance. Thus, R. E.: Low, moderate, forced, 
whisper = 5 feet, denotes that the whisper is heard at 
five feet and that it is the low, moderate or forced whisper, 
as the case may be, a line being drawn through each of the 
other two. If the examiner starts beyond the range of 
audition and gradually approaches, it will be found that 



FUNCTIONAL TESTS OF AUDITION 75 

the patient will not repeat the numbers correctly until the 
examiner is slightly nearer than if the opposite method is 
adopted. However, the difference is not usually of great 
consequence, but one should accustom himself to a uniform 
method. There is also considerable variation in the differ- 
ent numbers, when spoken with equal loudness, some being 
heard at a greater distance than others. Nevertheless, the 
test is fairly accurate and remains the most useful one 
by which the degree of impairment of hearing may be 
determined. 




Fig. 32. — Barany's noise apparatus. 

Voice. — When the whisper cannot be heard near the 
ear the voice is used, the conversational or the shouted 
voice, according to the degree of impairment of hearing. 
When one ear is very deaf and the other but slightly 
so, it may be impossible to exclude hearing in the good 
ear with the finger. If, after testing a patient in this 
manner, the finger is inserted into the meatus of the ear 
under examination and it produces no change in his 
answers, it is fair to assume that he had been hearing 
the spoken words with the opposite ear. In such a 
patient a noise producer may be used. There are various 
forms of this apparatus, perhaps the best known is 
Barany's (Fig. 32). This winds like a clock and produces 



76 



EXAMINATION OF THE PATIENT 



a rattling noise which is conveyed to the ear by inserting 
the hard-rubber tip into the meatus, and produces so 
much noise that even the shouted voice cannot be heard 
on the side to which it is appHed. When this is inserted 
into the good ear it is excluded and the test of the opposite 
ear becomes of value. 

Further tests are made to determine whether the lesion 
causing the deafness is located in the sound-conducting 
or the sound-perceiving mechanism. The sound-conduct- 
ing mechanism is that j^art of the auditory apparatus 
which transmits the sonorous vibrations to the labyrinthine 
fluid, and ccmsists of the external auditory canal, the 
membrana tympani, the middle ear including the ossic- 
ular chain, and the oval and round windows; the sound- 
perceiving mechanism is that part which analyzes these 
vibrations and inter])rets tliem as sound and inchides the 
acoustic labyrinth, the cochlear j)art of the eighth nerve 
and its central connections. 



I 




Fig. 33. — Dench fork for obtaining the lower tone limits. 

Tone Limits. — The normal range of audition is from 16 
double vibration (written D. V.) to upward of 30,000. 
The low^er tone limit is determined by a large tuning- 
fork. For ordinary work the Dench fork answers very 
well (Fig. 33). This is a large fork with clamps on the 
prongs. With these extended as far as possible about 
26 double vibrations per second are produced; with the 
ends of the clamps even with the prongs 32 I). V.; with 
the clamps removed 64 D. V. The clamps in any fork 
have a great influence in eliminating overtones, so when 
using a fork with them removed one should make sure that 



FUNCTIONAL TESTS OF AUDITION 77 

overtones are not present, as the patient may be able to 
hear them when he could not perceive the fundamental 
note of the fork. If after the fork is set in vibration the 
base of the prongs is lightly touched with the finger, the 
overtones will be eliminated. These low-pitched forks 
cause a vibration of air against the patient's ear or drum 
membrane, and he may interpret this sensation as sound 
and say that he hears the fork, when he has not heard 
the fundamental note at all. Only after he has described 
the sound should it be concluded that he has heard it. 
By the Dench fork it may be ascertained that the lower 
tone limit is below 26 D. V., which indicates that so far 
as this limit is concerned there is no marked variation 
from normal. On the other hand, if the lower tone limit is 
above 32 or 64, it indicates disease of the sound-conducting 
mechanism. Marked impairment of hearing in a patient 
whose lower tone limit is below 26 D. V. is evidence of 
involvement of the sound-perceiving mechanism. For 
more accurate tests of the range of audition the Bezold- 
Edelman continuous tone series is advised. This consists 
of a set of ten tuning-forks with clamps which slide upon 
the prongs by which device a practically continuous tone 
series from 16 double vibrations per second to 1024 D. Y. 
per second is obtained. For testing the tone perception 
above this point there are two closed pipes and an 
improved Gal ton whistle. It is possible with this set to 
determine the exact lower tone limit. 

Upper Tone Limit. — The upper tone limit may usually 
be determined by the Galton whistle (Fig. 34). This 
instrument is so constructed that the pitch is altered by 
turning a screw and sounds are thus emitted which 
represent the upper part of the musical scale. If the 
opposite ear is closed as completely as possible, and the 
screw gradually turned at the same time by intermittent 
pressure on the bulb, a succession of high-pitched chirps 
are emitted. As soon as the point is reached in the descend- 
ing scale at which the patient recognizes the sound as a 
musical note, the upper tone limit is determined. The 



78 EXAMINATION OF THE PATIENT 

blowing, hissing sound produced incidentally by the 
instrument is to be ignored. The examiner ascertains 
that the patient has perceived the musical, high-pitched 
note by having him describe it, which he usually does, 
likening it to a whistle, chirp, or squeak. As the closed 
tube in the instrument is lengthened and the pitch thus 
lowered, the length of the tube is registered on a gradu- 
ated scale. This number may be noted as upper tone 
limit 1, 2 or 3, etc., as the case may be; or if the Edelman 
instrument is used, it may be written in number of vibra- 
tions per second, this being ascertained from a corrected 
chart which accompanies the instrument. If it is desired to 
ascertain the luiml^er of vil)rati()ns in the ordinary instru- 
ment, it may be done, although roughly, by remembering 



Fig. 34. — Galton whistle modified by Dench. 

that according to the law of closed tubes, the tube length is 
one-fourth of the length of the sound wave.^ For example : 
if when the patient perceived the note the tube length 
as shown by the graduated scale is one-fourth inch, the 
sound wave would be one inch, and as sound travels at 
the rate of (approximately) 1100 feet per second, that is, 
13,200 inches, this would be the number of vibrations 
per second. Lowering of the upper tone limit indicates 
disease of the sound-perceiving mechanism. 

Gaps and Islands. — At times the tone perception may 
be lost throughout the greater part of the musical scale, 
so that only notes pitched in a small part of the register 

1 Dench, 3d edition, p. 149. 



FUNCTIONAL TESTS OF AUDITION 79 

are perceived. There may be one or more of these islands. 
Then, again, the patient may hear thronghout the greater 
part of the musical scale, being deaf for notes pitched in a 
small segment only. There may be one or more of these 
tone gaps. Tone islands and tone gaps indicate disease 
of the sound-perceiving mechanism. 

Bone Conduction. — In the normal ear bone conduction 
(written B. C.) is about half of air conduction (A. C). 
There is considerable variation in the ratio of B. C. to 
A. C. with forks of different pitch. As a rule, the higher 
the pitch of the fork, the shorter is the duration of bone 
conduction as compared with air conduction and vice 
versa. The best fork for these relative tests of bone 
conduction is an undamped one making 256 D. Y. per 
second. If a good fork of this pitch is set in vibration 
it will be heard by the normal ear for about 40 seconds. 
If when it is struck the handle is placed on the mastoid 
process, it will be heard for twenty seconds; if then held 
to the ear, it will be heard for twenty more seconds. That 
is, B. C. = I A. C. In diseases of the sound-conducting 
mechanism the bone conduction is increased both as 
compared with air conduction and with bone conduction 
in the normal ear. If in a normal person, after the fork 
is set in vibration, it is placed upon the vertex, the sound 
will be conducted to both ears with the same degree of 
intensity and will be heard about equally plain on the 
two sides. If, now, the finger is placed in one meatus, 
the sound immediately appears louder on that side. The 
finger in the ear acts very much as a lesion of the conduct- 
ing mechanism. There are two explanations of this 
increase of bone conduction in middle- and external-ear 
diseases which produce deafness. The impairment of 
hearing is evidently due, in these diseases, to an obstruc- 
tion to the entrance of sonorous vibrations which, there- 
fore, cannot reach the labyrinthine fluid to set it in 
vibration unless they are of sufficient intensity to over- 
come the obstruction. If, therefore, the labyrinthine 
fluid is caused to vibrate by impressions conducted through 



80 EXAMINATION OF THE PATIENT 

the bone, the organ of Corti with its central connections 
will be able to interpret these vibrations as sound. These 
intralabyrinthine vibrations naturally dissipate themselves 
by radiation in various directions but chiefly through 
the middle ear and external auditory canal, but, meeting 
with the same obstruction in these locations which causes 
the deafness, the vibrations are reflected back to the 
labyrinth and thus intensify the effect produced by the 
fork behind the ear or on the vertex and produce an 
increased bone conduction. Another explanation which 
has been offered is that the sound produced by bone 
conduction is intensified by the vibration of the column 
of air internal to the obstructing lesion. One can readily 
understand how this may take place when the cause of the 
deafness is occlusion of the meatus, as, for instance, a 
plug of cerumen, but this same phenomenon occurs when 
the lesion is at the foot-plate of the stapes on the very 
confines of the labyrinth and conse(|uently there is no 
column of air between it and the labyrintliinc fluid. So 
while some action cannot be denied to the vil)ration of 
the column of air it is probably of secondary importance 
in producing increased bone conduction. The increased 
bone conduction has given rise to three well-known tests: 
Rinne, Schwabach, and Weber. 

Rinne Test. — The Kinne test is a comparison of the 
bone conduction with the air conduction in the same ear. 
The normal reaction is a positive Rinne; with a 25() I). V. 
fork B. C. = § A. C. If the bone conduction increases 
and the air conduction diminishes, as it does in diseases 
of the sound-conducting mechanism, it may reach the 
point of reversal and B. C. will be greater than A. C, 
written B. C. >A. C. This is a negative Rinne. This 
usually occurs only when the impairment of hearing is 
marked. It may be expected when the forced whisper 
is heard at four feet or less. With less deafness than this 
the obstruction to the entrance of sonorous vibrations 
aerially conducted and the increase of bone conduction 
are not sufficient to reach the point of reversal; although 



FUNCTIONAL TESTS OF AUDITION 81 

there may be a change in the normal ratio of bone conduc- 
tion to air conduction. For example: B. C. = | A. C. 
This is a positive Rinne but a diminished positive and 
indicates disease of the sound-conducting mechanism. 
In the above remarks it is supposed that a good fork 
giving 256 D. V. is used. In disease of the sound-perceiving 
mechanism the Rinne is positive, that is, B. C. < A. C. 

Schwabach Test, — In this test the bone conduction of the 
ear examined is compared with that of the normal ear, for 
instance, that of the examiner. The test has absolutely 
nothing to do with air condition. There are two ways of 
making this test, according to whether the patient's bone 
conduction is increased or -diminished. The fork is struck 
and the handle placed upon the patient's mastoid process 
over the antrum; when he has ceased to hear it, it is 
transferred to the examiner's mastoid; when if heard, the 
bone conduction in the patient is less than normal, 
B.C. — . If the examiner, who is presumed to have normal 
bone conduction, fails to hear the fork, he may either have 
the same amount of bone conduction as the patient or 
less. To ascertain the condition the fork is again struck 
and if after the examiner ceases to hear it the patient does 
so, it is evident that the patient's bone conduction is 
increased, B.C. +. The amount of increase or diminution 
of the bone conduction may be taken in seconds, if desired. 
Ift order to ascertain the exact time at which the patient 
ceases hearing the fork he is directed to raise his hand when 
this occurs. He is also cautioned to be certain that he no 
longer hears the fork before doing this. The patient often 
seems to be uncertain on this point, either stating that he 
hears the fork when he does not or stating that he does 
not hear it, when if it is removed and then replaced he 
will hear it. This latter case may be due to fatigue of 
the auditory nerve in some instances but is far more often 
an evidence of inaccuracy on the part of the patient. 
If one ear is very deaf from disease of the sound-perceiving 
mechanism and the bone conduction in the other ear is 
good, the patient may hear the tuning-fork through the 
6 



82 EXAMINATION OF THE PATIENT 

head on the good side. So it is well, in order to avoid error, 
to ask the patient in which ear he hears the fork, which is 
placed upon the mastoid of the deafer ear. Increased 
bone conduction as obtained by the Schwabach test is 
an evidence of disease of the sound-conducting mechanism, 
and diminished bone conduction is evidence of disease of 
the sound-perceiving raechanism. 

Weber Test. — The Weber test is a comparison of the 
bone conduction on the two sides. In order to have it 
successful there must be quite marked inequality of hearing 
in the two ears and the patient must be fairly intelligent. 
The fork is struck and placed upon the vertex or against 
the teeth. The patient will hear it best in the deafer ear 
if there is disease of the sound-conducting mechanism. 
It may be written Weber + R. or L., as the case may be, 
or B. C. R. > L. or B. (\ R. < L., as the case may be. 
The statement of the patient is not always reliable in 
making this test, so if there is doubt of its accuracy it may 
be checked up with the Rinne and Schwabach tests. 

Both the Rinne and Schwabach tests are more or less 
unsatisfactory in patients over fifty years of age. As 
age advances bone conduction becomes less. It may be 
very poor in patients as young as forty-five, then again 
some patients of sixty have very good bone conduction. 
But it is uncertain in patients over fifty and so the tests 
in which its duration is an element becomes unsatisfactory. 
If in making these tests the patient is found to react as 
in younger subjects, reliance may be placed upon them. 
If, however, his bone conduction is evidently reduced, 
no deduction from this fact can be made. In locating the 
lesion in the sound-conducting mechanism in these older 
patients, reliance must be placed upon the occurrence of 
better bone conduction in the deafer ear, and upon 
elevation of the lower tone limit; in locating the lesion 
in the sound-perceiving mechanism, reliance must be 
placed upon bone conduction being better in the good 
ear, lowering of the upper tone limit, the occurrence of 
tone islands or gaps. 



FUNCTIONAL TESTS OF AUDITION 83 

Gelle Test. — This test is performed by setting the fork 
in motion and placing the handle on the skull. The air 
in the meatus is then condensed with the otoscope, or 
some similar apparatus. This forces the drum membrane 
and ossicular chain inward, leading to an increase in 
intralabyrinthine pressure. For this to take place it is 
supposed to be necessary for the stapes to be movable in 
the oval window. As the bulb is compressed, the fork 
should be perceived less plainly or not at all. If this 
occurs, the test is positive. A positive Gelle ought to 
indicate stapedial mobility. A negative test does not, 
however, indicate stapedial fixation, as other conditions 
may prevent the force exerted against the tympanic 
membrane from being conveyed to the labyrinthine fluid. 

Bing's Experivient. — Another test not commonly in 
use is Bing's experiment. If the bone conduction in a 
normal patient is taken and when he ceases to hear the 
fork the finger is inserted into the meatus, it becomes 
audible again. In marked deafness from conductive- 
mechanism disease this may not occur, as the finger may 
not offer any added obstruction to the exit of the vibrations 
and produce no increase in bone conduction. If the fork 
is not again heard by bone conduction when the finger is 
inserted, it is evidence of a lesion in the sound-conducting 
mechanism. However, not much reliance can with safety 
be placed upon this test in making a diagnosis of the 
location of the lesion. 



CHAPTER III. 
DISEASES OF THE EXTERNAL EAR. 

MALFORMATIONS. 

Polyotia. — Malformations of congenital origin may be 
limited to the auricle or the external auditory canal also 
may be affected. In polyotia more than one ear exists 
on the same side. One may be perfectly formed while 
the other is rudimentary, or both may be rudimentary. 
In the former case the meatus is usually properly formed 
and the surgeon is consulted on account of the deformity 
caused by the presence of the supernumerary ear. This 
may exist in the form of an extra lobule, or it may not 
resemble any of the structures of the auricle, merely being 
in the form of a tag which may or may not contain 
cartilaginous tissue. These tags are usually located 
anterior to the auricle (Fig. 35). They may be removed 
by an elliptical incision for the cosmetic effect. When 
both of the auricles are rudimentary various deformities 
of the deeper structures are usually present which are 
discussed under Microtia. 

Macrotia. — In macrotia there is an abnormal develop- 
ment of the auricle, either the pinna as a whole being too 
large or the increase in size is limited to certain parts of the 
ear, usually the lobule or the upper part of the auricle. 
Considerable variation in the size of the pinna is possible 
without the production of deformity providing the two 
ears are of the same size. If the auricles were symmetrical, 
although abnormally large, one would hesitate before 
operating upon them, as there is more or less danger of 
perichondritis in operations upon the auricle. 



MALFORMA TIOXS 



85 



If the lobule is very large a wedge-shaped piece may 
be removed and the parts sutured or held in place with 
^Michel's clamps. When the enlargement is in the upper 
part of the auricle a V-shaped piece may be removed and 
the margins of the wound brought together by two rows 
of sutiu'es, one on the anterior, and one on the posterior 
siu'face of the auricle. 




Fig. 35. — Polyotia. The auricle and canal normally developed, 
tags represent a supernumerary' auricle. 



The 



Microtia. — [Microtia is a term applied to abnormally 
small ears. As usually seen, they are very much deformed. 
There may be a rudimentary lobule, tragus and the upper 
part of the helix, or the auricle may be so deformed 
that it is impossible to make out any parts corresponding 
to the normal organ. In subjects with this deformity 
there is usually occlusion or total absence of the external 
auditory canal. The Eustachian tube may be patent and 
the tympanum normal, or these parts may be more or less 
deformed. ^lalformations of the inner ear may accompany 



86 DISEASES OF THE EXTERNAL EAR 

microtia, but this is not the rule. The condition results in 
more or less profound impairment of hearing. If both 
sides are affected, the question of operation arises to gain, if 
possible, a useful degree of hearing. While the report of 
operations has not been generally favorable, still success 
has been attained in some instances. The operation should 
be undertaken if the patient's parents desire it after being 
informed as to the uncertainty of the result. It should not 




Fig. 36. — Microtia (before operation). Dr. Page's patient (with 
permissioii) . 



be advised unless a trace of hearing is present and the 
bone conduction good, as if the labyrinth is simultaneously 
involved no good will be accomplished. The auricle is 
turned forward by a posterior incision. The mastoid 
antrum opened as widely as possible and the bone removed 
as far forward as would correspond to the anterior wall 
of the canal. The middle ear is thus opened. A good- 
sized meatus is formed in the skin and the wound lined 



MALFORMA TIONS 



87 



with Tiersch grafts. The cuts show the result of a case 
operated upon by Page^ (Figs. 36 and 37). 

Prominent Ears. — Occasionally the aurist is called upon 
to relieve the deformity caused by prominent ears. If 
seen in infancy the wearing of a tape cap may be advised. 




Fig. 37. — The same ear as in Fig. 36 after operation. With 
permission. 

This is so constructed that when in position the auricles 
are held in contact with the head by tapes passing over 
them. Continued wearing of this device results in the 
ears assuming a more normal position. The caps may be 
purchased in shops specializing in children's goods. In 



1 Tr. Am. Otolog. Soc, 1914. 



88 DISEASES OF THE EXTERNAL EAR 

adults the deformity may be due to a redundance of the 
cartilage or merely to a laxity of skin and contiguous 
tissue. In the former case in order to correct the deformity 
it is necessary to remove some of the cartilage or, as in 
an operation devised by Goldstein, to reduce the size of 
this structure by overlapping it. A curvilinear incision 
is made on the posterior surface of the auricle and the 
skin separated from the cartilage. This is now incised 
in a manner similar to that adopted in submucous resection 
of the septum, the incision merely passing through this 
structure and not the soft parts on the anterior surface 
of the auricle. These are now separated from the cartilage, 
the flaps of which are made to overlap and held in position 
by mattress sutures. The skin incision is then closed. 
Great care must be taken to avoid infection or perichon- 
dritis may result. If the soft tissues only are at fault 
an elliptical piece may be removed, of which part is taken 
from the posterior surface of the auricle and part from 
the tissues on the side of the head, or over the mastoid, 
and the incision brought together with deep and super- 
ficial sutures. Care must be taken to so locate this removal 
of tissue that the ear will assume a proper position when 
the flaps are brought together. 

Fistula. — This condition occurs as a small j^it usually 
in front of the auricle and is due to an incomplete closure 
of a branchial cleft. These fistuhe vary in depth from 
one-fourth of an inch to an inch and secrete a material 
not unlike sebaceous matter, which may be discharged 
externally or accumulate and become quite hard. At 
times they become inflamed, although usually they cause 
no discomfort. The inflammation will subside if the cavity 
is evacuated. For their radical cure they may be curetted, 
packed with gauze and allowed to heal from the bottom, 
but their total removal is advisable as resulting in less 
deformity. An elliptical incision is made and the walls 
of the fistula completely dissected out. The skin is brought 
together with clamps or sutures. Healing should result 
with an insignificant scar. 



CUTANEOUS DISEASES OF THE EXTERNAL EAR 89 

Bifid Lobule. — Bifid lobule is usually due to the tearing 
out of an ear-ring, but one is occasionally seen in which 
the patient denies all history of traumatism (Fig. 38). 
They may easily be remedied by freshening the separated 
margins and holding them together with sutures or Michel 
clamps. 




Fig. 38. — Lobule in three parts. The patient denies traumatism. Her 
daughter has a bifid lobule and also denies traumatism. 



CUTANEOUS DISEASES OF THE EXTERNAL EAR. 

The integument of the auricle and canal is subject to the 
various cutaneous diseases. It may be affected as part 
of a general cutaneous involvement when the patient will 
probably be seen by the dermatologist; or the ear alone 
may be affected when the otologist is usually consulted. 

Intertrigo. — This is usually a disease of infants and 
younger children and occurs in the fold behind the ear. 
It is caused by the contact of the opposing surfaces, either 
due to the natural position of the parts or brought about 
by the wearing of caps which press the auricle against the 
mastoid region. The parts become red and moist from the 



90 DISEASES OF THE EXTERNAL EAR 

inability of evaporation of the natural secretion to take 
place, the epithelium becomes macerated, exfoliates and 
decomposition occurs. Another form is caused by wearing 
bandages which are necessary after mastoid operations. 
These act by preventing the evaporation of the natural 
moisture which is augmented by the secretion from the 
mastoid wound. In this manner is produced maceration 
of the epithelium, irritation of the skin and exudation 
of a discharge, which decomposing becomes more or less 
odoriferous. Either of these forms may result in acute 
eczema, the latter being usually associated with it when 
well developed. Lack of cleanliness is also without 
doubt a frequent cause. 

Symptoms. — The symptoms are burning and pruritus. 
The child is continually trying to scratch the parts, and 
if there is a bandage he is trying to insert his finger 
beneath it and usually succeeds in infecting the mastoid 
wound if the bandage is not properly applied. 

Treatment. — The treatment consists in cleanliness and 
keeping the parts dry and separated. In the first form 
the parts are cleansed with soaj) and water not oftener 
than once a day. Subnitrate of bismuth or stearate 
of zinc may be dusted on every four hours or as often as 
the parts show a tendency to moisture. The wearing of 
caps binding the ears is discontinued. If the disease 
proves stubborn, oxide of zinc ointment may be used, 
and if necessary the parts may be separated by a small 
piece of lint upon which the ointment has been spread. 
When this condition occurs under mastoid dressings, 
treatment is often unsuccessful until the bandage can be 
left off. When changing the dressings the parts are to 
be thoroughly cleansed with pledgets of lint, and after- 
ward dusted w^ith stearate of zinc, or oxide of zinc oint- 
ment may be spread over the parts with a glass spatula 
or upon gauze which is applied to the involved surface. 
The bandage should be drawn tight over the cheek and 
neck to prevent, if possible, the child from inserting his 
fingers and producing further infection. 



CUTANEOUS DISEASES OF THE EXTERNAL EAR 91 

Eczema. — Eczema may be acute or chronic. The acute 
form is more often seen by the aurist, although occa- 
sionally it will have become chronic before it comes under 
observation. The chronic form is more apt to be but 
part of a general eczema of the face or scalp. Acute 
eczema insofar as it has a local cause, is due to the irri- 
tation from an aural discharge or from applications made 
by the patient, in the form of drops, liniments or oint- 
ments, for the relief of aural symptoms. It begins with 
the formation of vesicles, which rupture and exude a 
tenacious serum which dries into crusts or scales. If 
the disease progresses to a cure, these drop off and leave 
a red surface which gradually returns to normal. If the 
disease becomes subacute or chronic, as these scales and 
crusts come away, a weeping surface is left and new crusts 
form; the deeper layers of the skin become infiltrated 
and considerable thickening of the auricle or canal results, 
in the latter situation leading at times to a marked nar- 
rowing of the canal lumen. 

Symptoms. — The symptoms are a smarting sensation 
and pruritus. If the patient gives way to the desire to 
scratch the parts, the crusts may be torn away, resulting 
in bleeding and the formation of new crusts mixed with 
dried blood. Scratching the canal with ear spoons, 
matches, heads of pins, or the finger nail not infrequently 
results in infection and the production of a circumscribed 
otitis externa. When irritation from a middle-ear dis- 
charge causes the disease, the canal is moist and the 
formation of crusts does not take place, and there may be 
an area adjacent to the meatus in the same condition 
which appears red and denuded of epithelium. At the 
margin of the denuded area appear the crusts and scales 
characteristic of the disease. 

Treatment. — In treating this disease in patients who 
have no middle-ear discharge, the first endeavor is to 
ascertain whether the process is in the acute stage and 
demands sedative and emollient treatment, or whether 
it is more chronic and demands stimulation. In the 



92 DISEASES OF THE EXTERNAL EAR 

acute stage before the formation of crusts oxide of zinc 
ointment answers very well. This is applied twice a 
day. If the disease extends into the canal and it seems 
necessary to apply the ointment to this region, the patient 
may make a small applicator by winding cotton on a 
tooth-pick, with which the ointment is lightly applied 
to the canal walls. It is usually a bad plan, however, 
to apply oleaginous preparations to the meatus, and they 
should be avoided if possible. When crusts have formed 
in acute processes, they may be removed with soap and 
water or with olive oil, after which oxide of zinc ointment, 
to which has been added oil of cade 5 to 10 drops to the 
ounce, may be ai)plied two or three times daily. When 
the disease has become chronic or threatens to do so, 
the amount of oil of cade is increased as indicated from 
15 to ?){) or even (iO minims to the ounce, according to the 
amount of stimulation desired, and the crusts may he 
removed with green soa]). 

For eczemas resulting from middle-car discharge, as the 
condition is frequently caused by its imi)r()])er removal, 
cleanliness is essential. The secretion is to be removed 
every four hours or even oftener by syringing the ear 
with a saturated solution of boracic acid or bichloride, 1 
to 5000, after which the canal is to be driiMl and stearate 
of zinc or boracic acid applied by insufflation. The 
external parts are covered with oxide of zinc ointment to 
which the proper amount of oil of cade has l)een added. 
This may also be applied to the canal walls as advised 
above if the process proves stul)b()rn. It will, however, 
but seldom be necessary. Nitrate of silver, 2 to 6 
per cent, solution, may be applied to the canal once a 
day when other means fail. It should not be applied to 
the auricle on account of the discoloration which it 
causes. In chronic eczema, painting the auricle with 
cantharidal collodion often works well when other means 
fail. It should not be used oftener than every two to 
four days, according to the effect produced. The list of 
remedies which have been advocated is a long one. The 



CUTANEOUS DISEASES OF THE EXTERNAL EAR 93 

treatment outlined above will, however, usually be suc- 
cessful. The general health should be attended to, and 
any measures adopted which seem necessary. Cure may 
often be hastened by the administration of arsenic, iodide 
of iron, and cod-liver oil. 

Dermatitis. — This is an inflammation of the skin of the 
auricle due to irritants of various kinds. The most com- 
mon causes are: the application of heat by poultices, 
hot-water bottles or the direct rays of the sun; irritating 
linaments and ointments; freezing the ear by exposure. 
Any irritant, chemical or mechanical, is capable of pro- 
ducing this condition. Why in a given instance simple 
dermatitis rather than eczema is produced is at times 
difficult to understand. Some underlying systemic or 
local cause is probably necessary for the production of 
the latter condition. Varying with the degree of the 
irritation, simple redness of the skin, vesicles or inflam- 
mation of the deeper dermal layers may result. In 
severe burns and frost-bite destruction of the cartilage 
may accompany the dermatitis. 

Symptoms. — The symptoms vary from a burning, itching 
sensation to actual pain. If the cartilage is exposed, 
infection may occur, resulting in perichondritis. Upon 
inspection, the parts may be simply reddened or vesicles 
may be present, or the whole auricle may appear thickened 
and tender. If sloughing has occurred, the cartilage may 
be exposed. 

Treatment. — The treatment varies with the severity of 
the inflammation. In the milder forms some emollient 
ointment or cold cream is very efficacious. In the severer 
forms, application of compresses saturated in a 4 to 8 
per cent, solution of aluminum acetate, or acetate of 
lead, 4 grs. to the ounce, will often prove efficacious. If 
itching is severe, a solution of carbolic acid, 1 part in 
100 of water, ma}' be used. It is a matter of common 
knowledge that a frost-bitten ear should be ''thawed out'' 
with snow to prevent reaction. In the severer cases 
where there is destruction of skin with exposure of car- 



94 DISEASES OF THE EXTERNAL EAR 

tilage, the sloughs should be removed and the cartilage 
if necrotic dissected out, and the wound otherwise treated 
on general principles. 

Erysipelas. — Erysipelas is an inflammation of the skin, 
caused by infection. As usually seen by the aural surgeon, 
it develops subsequent to some operation on the mas- 
toid. It is due to infection with a streptococcus, but 
does not seem to occur with much more frequency after 
operations in which a strej^tococcus is the prevailing 
germ than in those in which this type of organism is 
absent. 

Symptoms. — The disease is usually ushered in by a 
chill which is followed by fever and it may be a day or 
so before the cutaneous lesions are sufficiently developed 
to enable one to make a diagnosis. In the meantime 
much anxiety is caused, as these same symptoms may 
occur with certain intracranial involvements following 
operations on the mastoid. There is usually pain and 
tenderness in the involved parts. Upon inspection there 
is a dull red, brawny infiltration of the skin which shows 
a well-marked line of demarcation. The auricle may be 
very much thickened and when the disease is fully devel- 
oped is covered with vesicles. Deep involvement of the 
middle ear or mastoid rarely occurs. It is not uncommon 
to see the grafts take well after a radical operation not- 
withstanding this disease. 

Diagnosis. — The diagnosis is made from simple der- 
matitis by the temperature and the presence of the line 
of demarcation. When this has formed it is character- 
istic. Occasionally the reaction caused by iodin which 
has been employed previous to operation closely resembles 
erysipelas. It will be found, however, that this does not 
extend from day to day, nor does it produce fever. The 
disease necessitates isolation. When they return from 
the isolation ward it is usually found that the wound has 
progressed satisfactorily. 

Prognosis. — The prognosis is usually good. IMost of 
the patients get well, although the disease is by no means 
free from danger. 



HERPES OF THE EXTERNAL EAR 95 

Treatment. — The treatment consists in the apphcation 
of a solution of acetate of lead, or aluminum acetate. 
The general condition of the patient should be attended 
to. Tr. chloride of iron in full doses still remains as good 
as any internal treatment. The administration of the 
leukocyte extract (His) has seemed to aid to a cure in 
some instances. As the patients usually get well it might 
naturally be expected that many forms of treatment 
would claim the credit — and this is the case. 

HERPES OF THE EXTERNAL EAR. 

Herpetic eruptions of the external ear, as compared 
with herpes zoster in other regions, is of uncommon 
occurrence. Herpes zoster may form in the area of dis- 
tribution of any of the cutaneous nerves which supply 
the auricle. The eruption may be located on the neck 
and head as well as on the posterior surface of the auricle 
in cervico-occipital involvement or on some part of the 
face and temporal region as well as on the anterior surface 
of the auricle in facial herpes. 

Herpes Zoster Oticus. — In one form distinct from 
these types, known as herpes zoster oticus, the lesions 
are more or less limited to the anterior surface of the 
auricle and auditory canal. It is usually accompanied 
by facial paralysis. In a patient of the author's, who had 
this type of herpes, the eruption was practically limited 
to the region of the concha, only a few vesicles appearing 
upon the antihelix and antitragus, the meatus and mem- 
brana tympani being free. Ramsey Hunt^ has brought this 
type to the notice of American otologists. He believes that 
the eruption occurs in the zoster zone of the geniculate 
ganglion and divides herpes zoster oticus into four groups : 
(1) herpes oticus; (2) herpes oticus with facial paraylsis; 

(3) herpes oticus with facial paralysis and hypo-acousis ; 

(4) herpes oticus with facial paralysis and Meniere's 

1 Journal of Nervous and Mental Disease, February, 1911; American 
Jour. Med. Sc, August, 1908. 



96 DISEASES OF THE EXTERNAL EAR 

symptom-complex. It is assumed that trophic and sen- 
sory nerves accompany the facial and are distributed to 
the skin of the auricle and canal. The geniculate ganglion 
is considered as analogous to the ganglia on the posterior 
roots of the spinal nerves, the pars intermedia of Wrisberg 
being the sensory root. This hypothesis accounts for 
the four varieties given above. Involvement of the 
ganglion, the motor fibers of the facial not' being impli- 
cated, produces neuralgia and the herpetic eruption. 
If the motor fibers are also involved, facial paralysis is 
added to these symptoms. In the third form, in which 
there is hypo-acousis or diminished hearing, this symptom 
is due to involvement of the cochlear branch of the 
eighth or perhaps to the peripheral ganglia (spiral gan- 
glion) which exists on this nerve. In the fourth group 
the vestibular branch of the eighth would be involved, 
in addition to the cochlear, accounting for the deafness, 
tinnitus, vertigo, vomiting and staggering gait, this being 
Meniere's symptom-complex. 

Symptoms. — Herpes begins with malaise and fever, 
usually of mild degree. Pain more or less severe follows. 
In a varying time, from one to several days, the parts 
become reddened, which is soon followed by the appear- 
ance of vesicles. These dry into scales and fall off in 
about a week, leaving a reddened base, which gradually 
fades. If facial paralysis occurs, it usually develops 
about the time of the appearance of the vesicles. The 
pain may subside when the vesicles appear or continue 
after they have healed. In some patients there is swelling 
of the auricle and external auditory canal and the eruption 
may occur on the membrana tympani and canal walls. 

Diagnosis. — The diagnosis offers no difficulty. The 
occurrence of pain w4th the characteristic eruption can 
hardly be mistaken for any other disease. 

Prognosis. — The prognosis is usually good. The erup- 
tion heals, the pain usually passes away and the facial 
paralysis, although in some patients quite persistent, 
usually gets well. 



OTITIS EXTERNA HEMORRHAGICA 97 

Treatment. — The treatment is antineuralgic. Phenace- 
tin, grs. V, every four hours, or aspirm, grs. x, four times 
a day, will be found useful. The ordinary migraine 
tablets, one every two hours, frequently ameliorate 
the pain. These contain acetanilid, 2 grs., monobromate 
of camphor and citrated caffeine | grain of each. Elec- 
tricity is at times of value to relieve the pain. It should 
be used both for this object and to maintain the nutrition 
of the facial muscles, in those patients in whom palsy is 
present. 



OTITIS EXTERNA HEMORRHAGICA. 

Closely allied to herpes in its SATuptoms and clinical 
course is the condition known as otitis externa hemor- 
rhagica. The lesion characteristic of this disease is pro- 
duced by a circumscribed effusion of blood or bloody 
serum beneath the epithelium of the external auditory 
canal. The favorite location of these blebs is on the 
floor of the canal near the drum membrane, although 
they may occur on any part of the canal wall or membrana 
tympani. They vary greatly in size and number in dif- 
ferent patients. They are of a dark blue color and do 
not seem to rest upon an inflamed base. One is frequently 
impressed with their resemblance to large herpetic 
vesicles containing blood in place of serum. 

Symptoms. — The most prominent symptom is pain. 
This is usually severe and sufficient to keep the patient 
awake at night. If the lesions are on the drum membrane, 
there is usually some deafness and tinnitus, but these 
symptoms do not usually cause much complaint on the 
part of the patient. Occasionally a patient comes on 
account of the bloody discharge which is caused by the 
rupture of the blebs. In patients seen by the writer the 
middle ear has usually been free from involvement, 
although Politzer states that he has often observed the 
disease accompanying otitis media of influenzal origin. 
7 



98 DISEASES OF THE EXTERNAL EAR 

Diagnosis. — The diagnosis is usually easily made. 
There is really no disease with which it can be confounded. 
The severe pain associated with hemorrhagic blebs is 
characteristic of this disease alone. It is not always 
easy to form an opinion as to the condition of the middle 
ear, when the lesions are situated on the drum membrane. 
Inflation may demonstrate that the tympanum is free 
from fluid, thus giving evidence that it is not involved. 

Prognosis. — The prognosis is good. The patients usu- 
ally recover in from a few days to a week or so. 

Treatment. — The treatment is antineuralgic. Phenace- 
tin, aspirin, or the neuralgic tablets may be given in the 
same manner as in herpes. The local treatment consists 
in opening the blebs, wi])ing the blood and serum away, 
and dusting the parts with boracic acid, or the blebs may 
be allowed to take care of themselves. In patients with 
the lesions on the drum membrane, especially if accom- 
panied with severe pain, if there is any doubt as to there 
being middle-ear involvement, a free myringotomy should 
be done after which the patient is treated the same as in 
otitis media. 

OTALGIA. 

Neuralgia affecting the region of the ear is termed 
otalgia. It may be a part of a general trigeminal or 
cervico-occipital neuralgia or the pain may be localized 
in the ear. When the auriculotemporal is involved, the 
pain is referred to the anterior surface of the auricle 
and pre-auricular region, while if the auricularis magnus 
and small occipital are affected the posterior surface of 
the auricle and mastoid region are the seat of the pain. 
There may be general hyperesthesia over the area supplied 
by the nerve, or tenderness may be limited to one or more 
points. The otalgia may be located in the deeper parts 
of the meatus or the tympanum, in which event the 
tympanic plexus is supposed to be involved. 

Etiology.^ — The predisposing causes of otalgia are 
anemia, malaria, hysteria and neurasthenia, but it is by 



OTALGIA 99 

no means infrequent in patients in whom none of these 
causes are operative. The most frequent exciting cause 
is some abnormal condition of the teeth, such as caries, 
eruption of molar teeth, bridge-work, or an impacted 
tooth not gro^-ing properly. Inflannnation *in and 
around the tonsil often produces severe pain in the ear, 
as does also involvement of the temporomaxillary articu- 
lation. Scars resulting from mastoid operations are 
occasionally the cause of severe neuralgic pain. 

Symptoms.— Some otalgias are of short duration. 
These are naturally those in which the cause can be 
found and removed. Others are chronic, recurring at 
intervals through months or years. It is not uncommon 
to see patients who complain that they have suffered 
from pain in the ear for months. The only important 
symptom is pain. This is usually quite intense during 
the height of the parox^'sm, but is not as continuous as 
in inflammatory affections of the middle ear and mas- 
toid. It is, however, usually sufBciently severe to keep 
the patient awake at night. 

Diagnosis. — The diagnosis is made upon the presence 
of pain and the absence of changes in the drum membrane 
and meatus. AMien there is h\'peresthesia over the 
mastoid region the tenderness may quite closely resemble 
that found in mastoid disease. The absence of signs of 
middle-ear involvement as well as the fact that the 
hyperesthesia of otalgia is apt to extend along the well- 
kno^Ti course of a nerve and outside of the mastoid area 
enable one to make a diagnosis. If the patient has 
instilled drops into the ear and these have produced 
changes in the membrana timpani, difficulty will arise. 
The aid of the .r-rays may be invoked when doubt is 
experienced. 

Prognosis. — When the cause can be found and relieved 
the prognosis is good. This is possible in the majority 
of patients who come under the care of the otologist. 
Of the minority some will be cured, while in others there 
may be recurring attacks of pain for some time. 



100 DISEASES OF THE EXTERNAL EAR 

Treatment. — In treating these patients search is made 
for the cause. The teeth demand the first attention. 
If they are not evidently carious or an erupting tooth 
cannot be found an .r-ray is taken. This may reveal 
a carious area, unsuspected before, or that the teeth are 
impacted and growing improperly. Inflammatory affec- 
tions of the tonsils are to be treated and peritonsillar 
abscesses opened. When the temporomaxillary articu- 
lation is involved, counterirritation and antirheumatic 
remedies may be used. ^Yhen the cause cannot be found 
or to relieve the pain pending its removal antineuralgic 
remedies may be given, ])henacetin, aspirin or the 
migraine tablets as directed under Herpes will be found 
useful. In the malarial patients, quinine and arsenic; 
in the anemic ones, tonics are to be administered. 



HEMATOMA AURIS. 

Hematoma auris is characterized by tlie effusion of 
blood or bloody seriun between the perichondrium and 
the auricular cartilage. 

Etiology. — It is common in the insane and in them 
seems to occur spontaneously. Just how nnich trauma- 
tism may have to do with causing it in these patients is 
undecided. That the mental state may have an effect 
seems probable in view of the experiments of Brown- 
Sequard, who found othematoma in animals in which 
the restiform body had been severed. As a result of 
traumatism it not infrequently occurs in the sane. 
Especially predisposed on account of their occupation 
are prize-fighters and acrobats. It seems probable that 
some degenerative change in the bloodvessels or cartilage 
is frequently a predisposing cause, as at times a severe 
trauma does not result in the production of an hematoma, 
while at others even a slight pull upon the ear is suffi- 
cient to cause one. These changes in prize-fighters and 
acrobats may be brought about by repeated traumatism. 



HEMATOMA AURIS 



101 



The disease is more common on the left side, both in the 
sane and the insane, which is an argument in favor of 
its traumatic origin. 

Symptoms. — Othematoma appears in the form of a 
tumor, either bhiish or of the color of the normal skin, 
usually situated on the anterior surface of the auricle 
(Fig. 39). In the beginning these enlargements feel 
doughy and are not tender on pressure. At this stage 




Fig. 39. — Othematoma. (Posey and Wright.) 

the patients rarely complain of pain but come for the 
relief of the deformity caused by the tumor. Later 
there may be pain especially if infection occurs. 

Diagnosis. — The only condition resembling this is 
perichondritis. The diagnosis is made from the history 
of traumatism, the presence of a well-defined tumor and 
absence of inflammation in hematoma. If transillu- 
minated the hematoma will appear opaque while peri- 
chondritis is more or less translucent (Politzer). If 



102 DISEASES OF THE EXTERNAL EAR 

infection occurs the process becomes one of perichondritis 
and should be treated as such. 

Treatment. — Spontaneous cure may result usually with 
more or less deformity. In the forming stage light press- 
ure with the application of cold will limit the size of the 
effusion. After the tumor is well formed, aseptic evacua- 
tion, either by aspiration or if this is unsuccessful by a 
small incision followed by the application of an aluminum 
acetate dressing firmly applied, is usually followed by 
good results. If the swelling l)ecomes painful and infection 
occurs or seems imminent a free incision should be made 
and the wound packed with gauze. At times even after 
the most skilful treatment deformity results from crump- 
ling of the cartilage, and this whether or not perichondritis 
has developed. 

PERICHONDRITIS OF THE AURICLE. 

Etiology. — Common causes are furuncles, infection of 
the meatal incision in the radical ()i)eration and hematoma 
of the auricle; although any injury of the auricle which 
becomes infected may produce the disease. The staphy- 
lococcus and pyocyaneus are the organisms which are 
usually responsil)le for perichondritis. In a j)atient of 
the author's the condition was due to scarlatinal infection 
following the radical operation. 

Pathology. — In this disease there is an inflammation 
of the perichondrium covering the cartilaginous frame- 
work of the auricle. As the lobule contains no cartilage, 
this is never involved. The region of concha adjacent 
to the meatus is frequently the part affected, mainly 
because the disease is more often due to processes within 
the meatus than to other causes, although any part of 
the auricle may be involved except the lobule. The 
inflammation of the perichondrium results in an ettusion 
between it and the cartilage. This eftusion is serous, 
colloidal, not unlike synovial fluid in consistence, or 
purulent, and as it forms the perichondrium is stripped 



PERICHOXDRITIS OF THE AURICLE 1Q3 

from the cartilage. This results in necrosis of the latter 
which thus becomes a foreign body. 

Sjnnptoms. — The s\TLiptoms are pain and a slight rise 
of temperature. The pain is not usually severe and the 
elevation of temperature is not more than two or three 
degrees. Upon inspecting the parts the auricle will be 
found thickened over the involved area, slightly red in 
color, tender on pressure with elevation of the local 
temperature. If effusion has taken place there will also 
be fluctuation. In the serous form, in which the effusion 
is usually limited, the reaction is less and the parts have 
a velvety feel. As the disease progresses and the eff\ision 
becomes greater and of a coUoidal or purulent nature, 
a well-defined tumor is formed, which if neglected ma}' 
rupture, resulting in the formation of fistula. 

Dia^osis. — The diagnosis is to be made from hematoma 
which it resembles when a well-marked timior has formed, 
by the inflammation which is present in perichondritis. 
The serous form may be mistaken for dermatitis, but the 
velvety sensation communicated to the fingers and the 
deeper location of the swelling in perichondritis usually 
enable one to diff'erentiate them. 

Prognosis. — After the process subsides even with the 
most skilful treatment some deformity of the am^icle 
usually remains, which in patients who have had no 
treatment is often very marked (Figs. 40 and 41). 

Treatment. — In the very early stages moist dressings 
of aluminum acetate may be applied. In the diffuse 
serous form this often affects a cure. If the eff\ision is 
localized and a tumor begins to form or signs of inflam- 
mation become well marked, a free incision should be 
made, the colloidal or purulent material evacuated and 
the necrotic cartilage removed with the curette. If in 
spite of this treatment the process extends so that more 
cartilage becomes involved, the incision should be enlarged 
and the necrosed cartilage dissected out. This is removed 
until healthy cartilage is encountered. This operation 
will result in minimizing the deformity, if it can be 



104 



DISEASES OF THE EXTERNAL EAR 



accomplished without weakening the outer part of the 
auricular framework. If a substantial rim of sound 




Fig. 40.- 



-Patient showing tlio (loforniily followiiiK perichondritis. 
Note that the lolmle is not involved. 




Fig. 41. — The opposite ear of the patient shown in Fig. 40. 



cartilage can be left, the operation is advisable; if not, 
little will be gained by it, and it is well to treat the process 
by free incisions and moist dressings. 



IMPACTED CERUMEN 105 

IMPACTED CERUMEN. 

Causation. — The ceruminous glands are situated in 
and beneath the skin in the outer or cartilaginous part 
of the external auditory canal. They are modified seba- 
ceous glands and secrete a yellowish, oily material — the 
cerumen. It is bitter in taste and is supposed to be 
designed by nature to discourage the entrance of insects, 
etc. Normally it lies in a thin layer covering a very 
limited area at the entrance to the meatus and as more 
is secreted moves outward and is removed either in wash- 
ing the ear or by the finger. At times, however, it accu- 
mulates and fills the meatus to a greater or less extent. 
This is due to increased secretion of cerumen of altered 
composition or to the shape of the canal. The move- 
ments of the inferior maxilla have an effect to stimulate 
the outward flow of the secretion but in some instances, 
in which cerumen is retained, the effect of the action of 
the condyle of the mandible upon the meatus seems to 
be directly the opposite, probably on account of the 
shape of the canal. As the secretion accumulates the 
mass is forced deeper into the canal either by the fresh 
secretion or by the patient's finger in his efforts to clear 
the ear until it may approach or even impinge upon the 
tympanic membrane. 

Pathology. — It is a very common condition. In some 
patients after being once removed it does not accumulate 
again. Others seem to have a recurrence at quite regular 
intervals, showing that nature is unable to take care of 
it. The mass w^hen removed consists of cerumen, more or 
less epithelial debris, sometimes various fungi. A foreign 
body, such as a piece of -cotton, may be found in the 
center of a ceruminous plug. The mass at times retains 
the shape of the canal and is covered with the epithelial 
lining of the meatus which has desquamated and adhered 
to the cerumen. Masses of cerumen lying on the walls 
of the canal are very frequently seen while making aural 
examinations. They may interfere with a view of the 



106 DISEASES OF THE EXTERNAL EAR 

deeper parts, and are easily removed with the dull ring 
curette. Usually it is not until the mass totally occludes 
the canal that symptoms are produced. This is very 
apt to occur after introduction of water which causes 
swelling or moving the plug or the same result is brought 
about by efforts on the part of the patient to clean the ear. 

Symptoms. — ^The usual symptoms are a feeling of ful- 
ness or stuffiness in the ear, a moderate degree of impaired 
hearing and tinnitus. The deafness will be much worse 
if the ceruminous plug has been forced into contact with 
the drum membrane, and in this event there may also 
be vertigo. The impairment of hearing will be found to 
be due to hivolvement of the sound-ccnuhicting mech- 
anism and should be taken before the cerumen is removed 
and again after. In this way should there be other causes 
for the deafness an estimate may be formed of liow much 
of the impairment of hearing was due to the cerumen. 
Cough may be caused by impacted cerumen. This is 
attributed to reflex action through tlie pneumogastric 
nerve brought about by irritation of its auricular branch 
(Arnold's nerve) which supplies the floor of the meatus. 
In all coughs not otherwise accounted for the ear should 
be examined. The color of the mass as seen on otoscopic 
examination is usually reddish brown, but may be white 
and glistening from being covered witli epithelial scales 
or cholesterin crystals. The impression conveyed to 
one is that the mass is much nearer than the membrana 
tympani could possibly be. If there is any doubt, it can 
be dispelled by the use of the probe which will show that 
its consistence is semisolid. 

Diagnosis. — The only condition apt to cause difficulty 
in diagnosis is a suppurative middle-ear process in which 
the secretion is so scanty that it dries in the meatus into 
a hard plug. Frequently, when the probe encounters 
these masses of dried pus they prove very hard. The 
diagnosis is not important, however, as the indications 
for treatment are the same in either event: namely, the 
removal of the mass. 



IMPACTED CERUMEN 107 

Prognosis. — One must not be too siire of relieving his 
patient of all s^^nptoms by the removal of the impacted 
cerumen, although he usually succeeds in doing so. The 
fact that these masses often occur in patients who have 
chronic catarrhal otitis media should be borne in mind, 
and also the possibility that they may consist of dried 
pus or cholesteatomatous masses from a chronic sup- 
purative middle-ear process. 

Treatment. — The best means to accomplish the removal 
of impacted cerumen is by the syringe, aided by the use 
of the ring curette, if necessary. Some aurists advocate 
the use of the curette alone. This, in many instances, 
will require great skill and be more disagreeable to the 
patient. There is practically no danger in syringing if 
properly performed. A warm antiseptic solution (bichlo- 
ride 1 to 5000 or saturated solution of boracic acid) is 
used and the mass removed at one sitting. The prelim- 
inary use of drops to soften the cerumen is not advised. 
The patient is entitled to the immediate and complete 
removal of the offending mass as soon as it is discovered. 
In syringing the ear for the removal of cerumen the object 
to be attained is to force some of the solution between 
the mass and the canal walls so that, accumulating internal 
to the plug, it will force the cerumen outward. To 
accomplish this the auricle is drawn upward and backward 
and the stream directed against the canal walls near the 
cerumen. Considerable force may be used in this manner 
without danger. The current is directed alternateh' 
against the different walls of the canal, with the object 
of finding some location where it may pass between the 
mass and the wall. A good-sized syringe is used, holding 
two or three ounces (Fig. 42). Sometimes great aid is 
afforded by illuminating the parts with reflected light. 
Seeing the canal enables one to give the proper direction 
to the stream. If some headway is not made after reason- 
able efforts, the curette may be inserted between tlie 
superior or posterior wall and the mass and a pail of the 
cerumen removed, or if possible a tunnel formed through 



108 DISEASES OF THE EXTERNAL EAR 

which the solution may be forced. Then by renewing 
the syringing and directing the stream at this point, the 
plug may be brought away. If still unsuccessful, more 
of the cerumen may be removed w^ith the curette, and 
the syringing renewed. With patience, by this method 
one will succeed. After the cerumen is removed the canal 
is dried with the cotton applicator to absorb the solution 
remaining in contact with the drum membrane and a 
careful inspection of this structure and of the canal 
walls made. Furuncles are not of infrequent occurrence 
after the removal of cerumen. So if any abraded sur- 
faces or points are found, they should be wiped with a 
solution of bichloride in alcohol (bichloride, gr. ^, alcohol, 
50 per cent., 5.])- This will also ])rcv(Mit the growth of 




Fig. 42. — Large aural syringe for removing cerumen. Capacity three 

oimces. 

fungi which at times form a considerable part of the 
ceruminous plug, the spores of which may still be adhering 
to the canal walls. If the weather is severe, a cotton 
wad mav be worn in the meatus for twent\'-f()ur hours. 



FOREIGN BODIES IN THE EXTERNAL AUDITORY 

CANAL. 

Various kinds of foreign bodies find their way into the 
external auditory canal. Cotton, beads, buttons, various 
kinds of seeds, insects or their larvtie, pieces of pencil, 
small pebbles, are among the commoner ones. Some are 
left in the ear by mistake, but by far the larger number 
are introduced by children, who seem to have a special 



FOREIGN BODIES IN THE AUDITORY CANAL 109 

disposition to get into trouble in this way. Otological 
literature is full of unique experiences with foreign bodies 
and the special means adopted for their extraction. 
They usually cause no trouble until unskilful attempts 
at their removal have been made. Exceptions are bodies 
that have been violently introduced, living bodies and 
seeds, as peas or beans which swell and cause pressure 
and occlusion of the meatus. It is not designed to mini- 
mize the seriousness of foreign bodies, for many of them 
are capable of causing great annoyance or even danger. 

Symptoms. — If the foreign body completely fills the 
canal, or if this is closed by swelling, there will be more 
or less deafness and perhaps also tinnitus with a feeling 
of fulness or stufhness in the ears. If the body is smaller 
and the parts have not been injured, it may produce no 
symptoms but become imbedded in the cerumen and 
remain for years unknown to the patient. On the other 
hand, such bodies may cause coughing and are supposed 
to have been the cause of epilepsy and various nervous 
disorders. If the canal wall has been injured, there will 
be swelling of the parts, with pain and a watery or bloody 
discharge. Rupture of the membrana tympani may be 
followed by otitis media with a purulent discharge. 
Bodies which enter the ear with force, such as bullets or 
pieces of metal, may penetrate the labyrinth and cause 
labyrinthitis and meningitis. In rare instances the body 
has been known to enter the tympanum through the 
Eustachian tube. 

Diagnosis. — The diagnosis is usually made from the 
history and by finding the body by reflected light. Sub- 
jects offering difficulty are those in which efforts at 
extraction have injured the canal walls, producing an 
otitis externa with narrowing of the lumen of the meatus 
so that the body, already forced quite deeply, is with 
difficulty made out through the narrow canal surrounded, 
as it is, by blood and secretions. Before attempting to 
remove a foreign body its presence should first be deter- 
mined. This advice is justified by the fact that the 



no DISEASES OF THE EXTERNAL EAR 

instances are not infrequent in which attempts at removal 
have been persevered in, until damage has been done, 
the operator never having seen the body but relying upon 
the statement by the patient that ''it must be in the ear.'' 
Treatment. — Ordinarily the removal of the body if 
seen at once is not difficult. It is still near the entrance 
of the meatus, and can be rolled out with the dull ring 
curette or a small hook. This is not applicable if the 
body is sufficiently large to occlude the canal, as the 
curette cannot be passed between it and the canal wall. 
If it is oval in form its position may be changed so that 
the curette or hook may be inserted. If there is no 
moisture, some adhesive material may be used. A camel- 
hair pencil dipped in glue and api)lied to the surface of 
the body soon dries and hardens, so that it may be 
removed by traction. A cotton pledget, a piece of paper, 
a long flat object or one presenting a small process, may 
with safety be extracted with the forceps. To attempt 
to use this instrinnent upon a smooth oval or round 
object only results in the forceps slipj^ing, thus forcing 
the body deeper into the canal, and if it i)asses the isth- 
mus its removal becomes much more difficult. Advan- 
tage should be taken of any holes, such as there are in 
beads, buttons, etc., which will enable the operator to 
insert a hook, thereby facilitating extraction. In chil- 
dren an anesthetic may be necessary, at times even before 
they will permit an examination. This should be given, 
as nothing of value can be accomplished with a struggling 
child. Sometimes by syringing, the body can be removed, 
or its position so changed that extraction becomes pos- 
sible. However, syringing as a matter of routine is not 
advised, although in the hands of those not possessing 
skill in aural work it is safer than any other procedure, 
and while it often succeeds, if it fails, no harm is done. 
Seeds such as peas, or beans that have swollen and become 
soft may sometimes be extracted by first removing the 
contents of the capsule, when this is easily removed with 
forceps. Destroying the vitality of a living body with 
chloroform or a strong solution of bichloride of mercury 



OTITIS EXTERNA DIFFUSA 111 

often facilitates its removal. A variation in the plan of 
procedure is often necessary to adapt it to special con- 
ditions. One finds use for all of his ingenuity in ovev- 
coming mechanical obstacles. 

Posterior Incision. — When all other means fail, it may 
become necessary to remove the body through a posterior 
incision. This is made behind and close to the auricle 
which is drawn forward and the canal exposed. The 
membranous canal is separated from the osseous meatus 
posteriorly and above, and incised near the location of 
the body. This may give sufficient room to extract the 
body, although it will usually be found necessary to 
remove part of the posterior and superior bony canal 
walls with the gouge, before one is able to effect its 
removal. This operation affords a direct approach and 
a more roomy field. It is, however, a procedure of last 
resort, but it is much better to adopt it than to persist 
in useless attempts by the other methods. It is also 
available w^hen bullets or pieces of metal have become 
imbedded in the tjinpanum or labyrinth, although, when 
this is the case, a much more extensive removal of the 
bone becomes necessary. After the operation is com- 
pleted, the auricle is replaced and sutured posteriorly 
and the canal packed with gauze to prevent, if possible, 
subsequent contraction. 

After-treatment. — After the removal of a foreign body 
by the other methods, the treatment varies according 
to the amount of injury done by the body or during its 
extraction. If the membrana tympani has been ruptured 
and the tympanum invaded, the treatment is the same 
as in otitis media; if the walls of the canal have been 
injured, the same as in otitis externa; while the simple 
cases require no treatment. 

OTITIS EXTERNA DIFFUSA. 

Definition. — Diffuse otitis externa is an inflammation 
of the meatus which, unlike furuncle, is not limited to 
any circumscribed area or areas. Two types are met 



112 DISEASES OF THE EXTERNAL EAR 

with. In one the inflammation involves the superficial 
layers of the skin, while in the other the deeper layers 
and the contiguous tissues are affected. 

Superficial Form. — In the superficial form, which may 
be called desquamative otitis externa, the epithelium is 
cast off, frequently leaving the canal wall red and dis- 
charging a w^atery material, although at times when 
the epithelial mass is removed the base is found dry. It 
is due to irritation from middle-ear discharge, instillation 
of solutions or mechanical injury. At times it is caused 
by cerumen. One form of desquamation occui;s in canals 
in which the cerumen is absent and is fairly attributable 
to the absence of this secretion. 

Symptoms. — The symptoms are pruritus and in some 
patients a serous discharge. The desire to scratch the 
ear seems irresistible and its gratification only results 
in aggravating the process, and at times in the produc- 
tion of a circumscribed otitis externa. Pain is rarely 
complained of, although some soreness upon movement 
of the auricle is not uncommonly present. Inspection 
shows the exfoliating epidermis either upon a dry base 
or lying upon a surface exuding moisture. When due 
to middle-ear discharge, the epidermal masses may be 
absent, the denuded canal walls appearing red and 
inflamed. 

Treatment. — The indications for treatment are to keep 
the parts dry and clean. The desquamating mass is to 
be removed and boracic acid or some other powder 
applied. In those processes caused by a middle-ear 
discharge, the parts are to be carefully dried after syring- 
ing and boracic acid insufflated. The mere cleansing 
of the parts in syringing has a beneficial effect. The 
pus should not be allowed to accumulate in the meatus 
and irritate the skin. In stubborn cases a . saturated 
solution of boracic acid in 50 per cent, alcohol may 
prove efficacious. 

Deep Form. — The deep form of otitis externa may not 
only involve the skin but the tissues adjacent to it. It 



OTITIS EXTERNA DIFFUSA 113 

is caused by injuries of the canal walls, by infection, 
either from middle-ear discharge or introduced from 
without; or by chemical or mechanical irritants. Lowered 
resistance is undoubtedly a predisposing cause. Judging 
from a study of the foreign literature, it would seem that 
the severe varieties of this type of otitis externa are much 
more common in Europe than in America. 

Pathology. — The process consists of inflammation and 
thickening of the canal walls, which may break down 
in places and cause abscesses and ulcers, from which 
granulations may spring. As usually seen, however, 
the process is in the stage of diffuse thickening of the 
meatus. 

Symptoms. — The patient complains of pain which may 
be very intense. There is tenderness upon moving the 
auricle or pressure which moves the cartilaginous canal. 
There may be pain during mastication. There may be 
fever, but the rise of temperature is not over a degree 
or two, except in the very severe types. If occlusion of 
the canal occurs either as a result of swelling of its walls 
or from accumulation of secretion, there will be deafness, 
perhaps also tinnitus. 

Diagnosis. — The diagnosis is made from furuncle by 
the fact that the thickening is diffuse, the swelling and 
tenderness not being localized as in furuncle. It may 
resemble certain forms of mastoiditis. (For differential 
diagnosis, see Mastoiditis.) 

Prognosis. — The disease may get well leaving the canal 
practically as before, or it may pass into a chronic state 
resulting in a greater or less degree of stenosis of the 
meatus. 

Treatment. — The treatment consists in irrigating the 
ear with warm antiseptic solutions, or packing the canal 
with gauze saturated with 4 to 8 per cent, solution of 
aluminum acetate. In ■ severe processes which persist 
notwithstanding these measures, free incision of the 
canal walls becomes necessary. Several longitudinal 
cuts should be made through the soft parts to the bone 
8 



114 DISEASES OF THE EXTERNAL EAR 

and cartilage, after which hot irrigations or the gauze 
packing should be resorted to. P'requeiitly, the applica- 
tion of moist heat to the auricular region gives relief from 
the pain and seems to have a beneficial effect upon the 
process. 

OTOMYCOSIS. 

Otomycosis may be considered as a form of otitis externa 
due to the growth of fungi or mould in the meatus. 

Causation. — There are a great many fungi capable of 
producing this disease, but those most frequently found 




Fig. 43. — Asperj2;ilhis (Burnett). «, asporjiillus ^laucus; 6 and c, different 
stages of the growth of the sporangea of the aspergiUus nigricans. 

are the varieties of the aspergillus — niger, flavus and 
fumigatus (Figs. 43 and 44). x\ll of t^he reasons for their 
being able to grow in some patients and not in others 
are not known. Oleaginous preparations favor the 
growth of certain varieties. These preparations are very 
popular with the laity, still otomycosis cannot be con- 
sidered a common disease. Dampness seems to favor 
other forms. Ceruminous masses are frequently found to 
contain these fungi. 

Symptoms. — In some patients considerable masses of 
these fungi may be in the ear without noticeable incon- 
venience. In others reaction of the skin takes place and 



OTOMYCOSIS 115 

pain and pruritus may be produced. There may also 
be a discharge of watery material. Still in a great many 
instances the ears are dry. It is when the mould invades 
the tissues, either of the canal or the drum membrane, 
that symptoms are caused. If the growth produces 
a perforation of the latter structure, as they have been 
known to do, or if one exists, otherwise formed, the 
fungi may invade the tympanum, causing an otitis media. 
Upon inspection of the canal the appearance varies with 
nature of the fungus and the location of its growth. In 
the aspergillus niger the growth is covered with dark 




Fig. 44. — Aspergillus (Burnett). Mycelial web before sporangea have 

develoDed. 



developed. 

spots, the sporangea, while in the flavus the masses are 
of a brownish-yellow color. They may be found upon 
the canal walls or upon the membrana tympani. The 
superficial layers of the skin exfoliate, leaving a moist 
surface. Sometimes the masses consisting of fungi and 
epithelial scales accumulate in sufficient quantity to 
occlude the lumen of the canal. In such instances there 
will be diminution of hearing, perhaps tinnitus as well. 

Diagnosis. — The diagnosis is made from the charac- 
teristic appearance of the masses and the results of 
the microscopic examination of some of the material 
removed. 



116 DISEASES OF THE EXTERNAL EAR 

Prognosis. — The prognosis as a rule is good. It will 
usually be possible to cure the disease which they cause 
by destroying the vitality of the fungi. 

Treatment. — In the treatment of this disease alcohol 
is a sovereign remedy. It is to be used as strong as the 
patient is able to bear it; beginning with 50 per cent, 
and increasing until pain is produced or 95 per cent, 
strength is reached. Bichloride of mercury 1 to 2000 
in the alcohol adds materially to its action. The canal 
is first cleared of the growth as far as possil)le either by 
syringing or with the applicator, then after drying the 
parts the external . canal is filled with the alcoholic solu- 
tion, which is allowed to remain ten to twenty minutes. 
The cleansing of the canal need not be repeated unless 
found necessary, but the use of the alcohol should be 
repeated from two to four times a day imtil cure is com- 
plete. 

OTITIS EXTERNA CIRCUMSCRIPTA. 

Furuncle. 

Causation. — Circumscribed external otitis or furimcle 
is a very common condition and is due to the entrance 
of bacteria into the glands of the external meatus, fre- 
quently after an abrasion. These abrasions are com- 
monly produced by scratching the ear with the finger 
or some instrument which tlie patient uses, or they may 
result from injury inflicted while removing cerumen or 
a foreign body. The prevailing organism from pus taken 
from furuncles is the staphylococcus, although a circum- 
scribed inflammation of the canal is occasionally produced 
by other germs, usually when it is secondary to middle- 
ear suppuration. Lack of resistance on the part of the 
patient is also, without doubt, frequently a factor in 
causation. The ceruminous glands and hair follicles are 
found only in the outer part of the canal. This makes 
a furuncle near the drum membrane an impossibility. 
A circumscribed inflammation at the fundus of the canal 



OTITIS EXTERNA CIRCUMSCRIPTA 117 

is therefore to be considered as evidence of mastoid or 
middle-ear involvement. Furuncles are rare in young 
children. 

Symptoms. — Circumscribed otitis externa usually begins 
with a stinging sensation, followed by soreness or pain 
upon moving the auricle or pressing upon the external 
auditory canal. Soon, if the infection is severe, there will 
be spontaneous pain. As the swelling increases and the 
canal becomes occluded, there is deafness and at times 
tinnitus. Furuncles may be divided into the superficial 
and deep varieties. In the first, the sw^elling is small 
and red and very soon show^s a pustular summit. In 
the second, the swelling is larger, the redness is slower 
in appearing and considerable time (several days to a 
week) elapses before the skin breaks down, so that in 
some instances, the resistance being less in this direction, 
the pus may break through the canal wall and form an 
abscess adjacent to the auricle. In the superficial variety 
the abscess is often evacuated spontaneously without 
marked symptqms or swelling. In the deep, the pain 
and tenderness are more severe. If the furuncle is situated 
on the anterior canal wall, there is frequently pain, during 
mastication, from the condyle of the mandible disturbing 
the inflamed tissues. There may be edema of the tissues 
around the auricle. Fever is an occasional symptom but 
rarely a marked one. The rise of temperature is not over 
one or two degrees. If it is more than this in a patient 
supposed to have furuncle, the diagnosis should be care- 
fully investigated. 

Diagnosis. — ^At times the diagnosis of furuncle presents 
no difficulties. By inspection one sees a well-defined 
swelling w^ithin the meatus. Pain is elicited upon move- 
ment of the auricle or by pressing upon the swollen area. 
Careful introduction of the speculum demonstrates that 
the membrana tympani is normal as to color and luster 
and that the fundus of the canal is not contracted. There 
is nothing for which this picture can be mistaken. On 
the other hand, in patients with occlusion of the meatus, 



118 DISEASES OF THE EXTERNAL EAR 

with retro-auricular edema, the process may be mistaken 
for mastoiditis. If by using a small speculum a view of 
the fundus can be obtained and there is normal or nearly 
normal membrana tympani with no narrowing of the 
canal near the membrane, pain being present upon moving 
the auricle or canal and absent upon pressure over the 
mastoid, the process is one of furuncle. In examining 
the mastoid for tenderness in these patients great care 
should be taken that the thumb does not touch or move 
the auricle or external auditory canal, as this always pro- 
duces pain in furuncle. When there is involvement of 
the middle ear and mastoid and the pus has reached the 
posterior wall either by dissecting its way out through the 
Rivinian segment or through the mastoid by a j)erf()ration 
on the posterior osseous canal wall, the resemblance to 
furuncle is quite marked. This subperiosteal accumula- 
tion of pus produces a swelling in the superficial part 
of the meatus and if it ruptures or is incised there is a 
discharge. Both of these conditions are a])parently 
characteristic of furuncle. As there is a. great ditterence 
in the treatment to be adopted, the differential diagnosis 
becomes of importance. Reliance is to be placed upon 
the following: (1) pain on movement of auricle present 
in furuncle, almost certainly absent in mastoiditis; (2) 
narrowing of canal near outer end in furuncle; at inner 
end contiguous to membrana tym])ani in mastoiditis. 
It is evident that if pus has dissected its way out beneath 
the attachment of Shrapnell's membrane the narrowing 
will extend to the fundus. If it reaches the canal through 
a perforation in the posterior bony wall, there is apt to 
be narrowing at the fundus, from mastoid involvement; 
(3) in furuncle the membrana tympani should be normal 
or nearly so. In acute purulent otitis media and mas- 
toiditis the characteristic changes will be present; (4) 
if the abscess is opened the probe does not encounter 
bare bone in furuncle, except in rare instances. In mas- 
toiditis, as the pus is subperiosteal, bare bone is always 
present or the probe may enter the mastoid through the 



OTITIS EXTERNA CIRCUMSCRIPTA 119 

perforation; (5) pus from a furuncle usually contains 
the staphylococcus and is less in amount. In mastoiditis 
this germ is not so common and the discharge is more 
copious; (6) finally the .r-rays may give valuable informa- 
tion in doubtful cases. 

Treatment. — Some small furuncles may be allowed to 
pursue their course without treatment. Others if seen 
early are relieved by packing the canal with gauze sat- 
urated with a 4 to 8 per cent, solution of aluminum 
acetate. A narrow strand of gauze, first dipped into the 
solution, is then packed into the canal with a moderate 
degree of firmness and the patient is supplied with the 
solution and a few drops are occasionally placed upon 
the gauze to prevent its becoming dry. When there is 
severe pain, an early and free incision is the best treatment. 
If the swelling is of an oval form and well marked, the 
incision is made through the most prominent part, in 
the line of the canal and down to the cartilage or bone. 
If the prominence of the swelling cannot be made out 
readily, the point of greatest tenderness is ascertained by 
pressure with a cotton-tipped applicator and the longi- 
tudinal incision is made through it. If more than one 
tender point exists, an incision is made through each one. 
If the furuncle is a large one and has broken down, a strip 
of gauze may be inserted into the cavity for drainage. 
This is removed in twenty-four hours and another inserted 
if necessary. If the abscess is small or incised early, the 
canal may be packed w^ith aluminum acetate gauze or 
syringed with bichloride or boracic acid solution. Pack- 
ing the canal with gauze seems to more quickly relieve 
the swelling which frequently persists even after a free 
and sufficient incision. If the abscess has been neglected 
and points externally a counter opening may be neces- 
sary to insure sufficient drainage. This may be made 
freely, bearing in mind the anatomical structures to be 
encountered, gauze inserted and a moist dressing, either 
of aluminum acetate or saline, applied. At times as 
furuncles are healing, exuberant granulations, very much 



120 DISEASES OF THE EXTERNAL EAR 

resembling aural polj^DS, develop. These are to be 
removed with the sharp curette and their bases cauterized 
with the fused bead of silver nitrate. To prevent the 
occurrence of successive furuncles, an effort to prevent 
reinfection is made. Perhaps the best means to accom- 
plish this is the instillation of the alcohol and bichloride 
solution. The patient is also cautioned as to scratching 
the ear with pins, ear spoons or other objects. 

The internal treatment of furunculosis must not be 
neglected. Formerly great reliance was placed upon 
the compound syrup of hypophosphites which was much 
superior to the sulphide of calcium treatment once in 
vogue. The success attained l)y the emj^loyment of an 
autogenous vaccine is so great that it has supplanted 
other forms of general treatment. In every instance, 
when the incision is made, if jnis is i)resent, a culture 
should be taken so that, should a subsequent furuncle 
develop or the one incised be slow in healing, the vaccine 
may l)e at hand and administered. 

EXOSTOSIS. 

Bony growths from the osseous wall of the meatus are 
called exostoses. There may be either a diffuse osseous 
thickening or the new formation may exist as a well- 
defined tumor. Formerly the diffuse growths were called 
hyperostoses, but it is customary at ])resent to make no 
distinction but to include them all under the term exos- 
toses. These enlargements may be multiple or single, 
may be limited to one side or be bilateral. They may 
occur at the entrance of the osseous portion of the meatus 
or near the membrana tympani. There is no part of the 
bony canal that is exempt from them. 

Causation. — Various causes have been assigned for the 
formation of exostoses but little is definitely known. 
There is no doubt but that a chronic suppuration of the 
middle ear may act as a causative factor. The author 
has observed two patients in whom there was involvement 



EXOSTOSIS 



121 



of the anterior canal wall in leontiasis ossea. In one 
enlargement of the mandible occurred on both sides, but 
the exostosis was unilateral, while in the other (Fig. 45) 
the mandible was enlarged on one side only, that of the 
exostosis, and there was also a suppurative otitis media 
on this side. They have been found with uncommon 
frequency in Peruvian skulls and in those of the mound 
builders. 




Fig. 45. — Patient with leontiasis ossea who had exostosis on the anterior 
wall of the external meatus. 



Symptoms. — When symptoms are present, they are 
caused by the growths attaining sufficient size to obstruct 
the lumen of the canal or by the same result being accom- 
plished by the retention of secretions internal to them. 
So long as the growths are small the patient may be 
unaware of their presence. One sees these exostoses from 
time to time in patients who have sought advice for 
some condition totally unconnected with them. As long 
as there is an opening in the canal and no secretion accu- 
mulates, these patients seem to hear about normally. 
When the patient comes on account of impaired hearing, 
tinnitus or a stuffy feeling in his ears, due to the disease, 
upon examination the growth or growths are found more 



122 DISEASES OF THE EXTERNAL EAR 

or less completely blocking the canal or the meatus is 
found narrowed by diffuse thickening. The probe shows 
them to be hard, resistant and not tender. They may 
have a broad base or this may be constricted so that they 
appear somewhat pedunculated. If the canal is blocked 
in a patient having a suppurative otitis media, there 
will be symptoms due to the lack of drainage and any 
of the complications given under Purulent Otitis Media 
may arise. When no symptoms are produced, they are 
usually discovered accidentally and either project into 
the canal as one or more small nodules or as an elevated 
area leading to contraction but not occlusion of the 
meatus. Exostoses at the junction of the fibrous and 
osseous portions of the canal are more apt to produce 
symptoms than those near the meml)rana tympani, as 
they lead more readily to the retention of cerumen, 
ei)ithelial debris, etc. 

Diagnosis.— The diagnosis as a rule presents no diffi- 
culty. The growth is seen and the ])robe shows it to 
be hard and firm. If the skin covering the exostoses is 
inflamed, thickened or ulcerated, there may be doubt 
but this would be dissipated by the use of the probe. 
To determine whether or not an otitis medis purulenta 
is present may be difficult. One would rely on the char- 
acter of the discharge, if there was one or if drainage was 
completely blocked, the occiUTence of symptoms point- 
ing to some complication of middle-ear supi)uration. In 
exceptional instances the question may not be settled 
until operation. 

Prognosis. — Exostoses may be removed and they do 
not recur. There is, however, considerable difficulty in 
maintaining a free and sufficient meatus. There seems to 
be a special tendency for the parts to contract after the 
removal of exostoses. Either the bone becomes thickened 
or cicatricial tissue forms before the wound becomes 
dermatized. 

Treatment. — If the exostosis is of small size, it requires 
no treatment. The patient should be seen from time to 



EXOSTOSIS 123 

time and the secretions removed. If it is so large that 
this becomes difRcuh or if it occludes the lumen of the 
canal, its removal by operation is indicated. If it leads 
to the retention of secretion in a suppurative otitis media, 
operation and the establishment of drainage is impera- 
tive. An exostosis with small peduncle may be removed 
with the gouge through the natural opening, but growths 
offering a prospect of success by this method are rare. 
Operation by a postauricular incision is usually the best, 
as it leaves a better meatus. An incision to the bone 
behind the auricle is made. The soft parts are elevated 
from the bone and the skin lining the meatus is carefully 
separated until the exostosis is exposed. This is then 
removed with the gouge, taking care not to injure the 
drum membrane. As much bone as possible is removed 
with the growth. The amount of this will vary with its 
location. If situated upon the inferior, superior or 
anterior wall, less, as a rule, can be taken. It is a good 
plan in this case to remove as much of the posterior wall 
as possible to increase the size of the meatus, that it may 
be sufRciently large notwithstanding subsequent con- 
traction. If the exostosis is situated on the posterior 
wall, the bone removal is done with as little disturbance 
to the other walls and their cutaneous coverings as pos- 
sible. If there is a suppurative otitis media, operative 
procedures for its relief may be combined with the removal 
of the exostosis. A flap is now cut in the meatus and 
concha, as described under the radical operation. It is 
preferable at this stage to cover all of the denuded bone 
with Thiersch grafts. If these take, the packing is removed 
in four days and the cavity cleansed by syringing, then 
wiping with peroxide, one-half strength of the 10-volume 
solution, followed by alcohol and bichloride 1 to 2000. 
If the graft does not take or has not been inserted, the 
canal should be firmly packed to keep down granulations. 
(See Care of Radical Cavities.) The posterior incision is 
closed by clamps or sutures and usually heals promptly. 



124 DISEASES OF THE EXTERNAL EAR 

STRICTURES AND ATRESIA OF THE MEATUS. 

Contraction and occlusion of the meatus has been 
considered as producing symptoms in the various diseases 
of the external ear, the condition passing away with the 
cure of the disease. Patients present, however, in whom 
the contraction or atresia is a diseased condition by itself. 

Pathology. — A stricture is a contraction of the lumen 
of the meatus, while an atresia is a total (obstruction. 
The strictures are usually a result of an inflammatory 
process, with fcxrmation of new connective tissue, in the 
canal walls. If while the ])r()cess is active and the canal 
walls are in contact abrasion of the ()pi)()sing surfaces 
occurs, they adhere and an atresia is the result. If this 
adhesion is limited in extent a diaphragm-like membrane 
may follow; if more extensive, a thicker atresia is ])ro- 
duced. One type of narrowing of the canal is found in 
old peo])le and occasionally after the mastoid ()])erati()n. 
The walls of the cartilaginous i)()rtion of the canal lie in 
contact so that sound waves cannot enter, and also allow- 
ing secretion to be retained. This type is due to atrophy 
of the cartilage in the canal walls so that it no longer 
serves to hold them a])art. If the speculum is introduced, 
the canal remains ()])en while it is in position but falls 
together when the sj)eculum is removed. 

Symptoms. — Strictures only produce symptoms when 
they lead to retention of secretions. The natural moisture 
of the skin of the canal internal to them being retained 
macerates the epithelium. This often decomposes and 
becomes foul-smelling. This material blocks the meatus 
and leads to deafness and perhaps tinnitus. As long as a 
small opening remains through the stricture and there 
is no moisture internal to it the patient hears very well, 
a very small opening being sufficient, apparently, to 
conduct the sonorous vibrations to the drum membrane. 
In atresias, as not even a small opening remains, there 
is always some impairment of hearing, the degree depend- 
ing upon the thickness of the obstructing membrane. 



SEBACEOUS CYSTS 125 

When this is diaphragmatic and thin, deafness is not 
marked, unless secretion has accumulated internal to it. 
If the atresia is a thick one, and especially if it extends to 
the drum membrane, impairment of hearing is profound. 

Diagnosis. — The diagnosis is usually easily made. 
Membranous atresias near the drum membrane may 
resemble this structure. The absence of landmarks and 
the fact that the canal is not as deep as normal, establishes 
the diagnosis. Comparison with the opposite side may 
aid one to determine their nature. 

Treatment. — When there is no accumulation internal 
to the stricture, no treatment is necessary. If an accumula- 
tion is present, it is to be removed and the parts dusted 
with boracic acid. If there is middle-ear suppuration, 
a stricture interferes with treatment and an operation 
may be necessary. A thin diaphragmatic atresia may 
be incised and as much as possible of the membrane 
removed. For the thick atresias an operation, performed 
in a manner similar to the operation in exostosis, is neces- 
sary. The thickened walls are to be dissected out and the 
meatus enlarged by removing the posterior osseous canal 
wall. The cavity lined with grafts and a conchal flap 
made as in the radical operation. 

In the type of stenosis occurring in old people and after 
the mastoid operation, a rubber tube may be worn, or a 
plastic operation to form a large meatus may be under- 
taken. 

SEBACEOUS CYSTS. 

Sebaceous cysts are of common occurrence on and 
around the auricle. Their favorite location is on the 
posterior surface of the lobule, although they may occur 
on any part of the auricle or even in the meatus. They 
are due to occlusion of the orifice of a sebaceous gland 
with the consequent retention of its secretion. They 
usually give rise to no symptoms unless located in the 
meatus, or they become inflamed. If a sebaceous cyst 
is removed entire together with its wall, it will not recur. 



126 DISEASES OF THE EXTERNAL EAR 

Treatment. — Two methods of treatment may be adopted. 
Either they may be incised, the cyst cavity evacuated, 
its walls curetted, then packed with gauze so that heal- 
ing from the bottom takes place; or the cysts may be 
dissected out. The latter plan is better, leaving less 
cicatrix. An elliptical incision is made and the sac care- 
fully separated from the surroiniding tissue. If rupture 
occurs, the entire sac is to be removed. The wound 
heals with a linear scar which is scared v noticeable. 



TUMORS OF THE EXTERNAL EAR. 

The external ear is subject to all of the tumors, both 
malignant and benign, which may occur in cutaneous, 
fibrous or cartilaginous structures in other regions, but 
as they are not of special otological interest, the student 
is referred to books on general surgery for their study. 



CHAPTER IV. 

DISEASES OF THE MEMBRAXA TYMPAXL 

The membrana tympani, dividing as it does the middle 
from the external ear, is common to both of these parts. 
Its external layer is continuous with the epithelial lining 
of the external auditory canal, its internal layer is a 
modified mucous membrane continuous with that of the 
middle ear, ^vhile between the two is the lamina propria, 
formed of connective tissue. This structure, consisting 
of epithelium, connective tissue and mucous membrane, 
is naturally subject to all of the diseases that affect these 
tissues. While almost all of the pathological processes 
which are observed in the membrana tympani are second- 
ary to disease in the external auditory canal or middle 
ear, still occasionally disease develops in the structure 
as a primary process. 

ACUTE MYRINGITIS. 

Acute myringitis is an acute inflammation of the drum 
membrane and the term is used to apply to primary 
processes in this structure. If the epithelial layer is 
involved, there is an effusion and the formation of one 
or more blebs, which usually contain serum. If the 
fibrous layer becomes inflamed, an abscess may result 
which may rupture externally or into the middle ear. 
In the latter event an acute otitis media will result. 
Inflammation of the mucous layer is conceivable but it 
could not be recognized clinically as a process independent 
of otitis media. 

Etiology. — The causes of acute myringitis are the appli- 
cation of irritating substances, mechanical u-ritation, cold 



128 DISEASES OF THE MEMBRANA TYMPANI 

in the form of air or snow, and blows upon the ear not 
sufficient to cause rupture of the membrane, or the cause 
may be undiscoverable. 

Symptoms. — There is pain, usually not as severe as in 
the acute inflammations of the middle ear. There may 
be slight tinnitus and some impairment of hearing. The 
symptoms vary in intensity witli the severity of the 
process. 

Diagnosis. — If one or more blebs arc seen on the mcin- 
brana tcnsa, the meml)rane otherwise being nearly nor- 
mal, and inflation demonstrates that the middle ear is 
dry, one is justified in considering the process as myrin- 
gitis. If the process clears uj) in a few days with return 
to normal hearing, without involvement of the middle 
ear, the correctness of the diagnosis is established. A 
vsmall abscess in the fibrous layer would cause greater 
difficulty in diagnosis. If the swelling is circumscribed, 
the membrane otherwise nearly normal and the middle 
ear is dry, it would be fair to assume that the condition 
was one of myringitis affecting the lamina propria. 
However, the differential diagnosis from otitis media may 
be hnpossible. It nuist be remembered that the primary 
inflammations of the drum membrane are very rare, 
while hiflammations of the middle ear are very common, 
and this fact should have due weight in making the 
diagnosis. 

Prognosis. — Acute myringitis usually runs its course in 
a few days but it may become chronic or rupture may 
take place into the tympanum, resulting in otitis media 
purulenta. 

Treatment. — The blebs may be opened, allowed to 
drain and boracic acid insufflated. This forms a crust 
which falls off in a few days. In patients who do not 
have these blebs but in whom the process is evidently 
mild in nature, irrigation with warm bichloride solution 
will relieve the symptoms and aid recovery. When there 
is a circumscribed thickening in the membrane, indi- 
cating abscess formation, as shown by its yellow color, 



TRAUMATIC RUPTURE OF MEMBRANA TYMPANI 129 

an attempt may be made to incise it without perforat- 
ing the membrane. If this is impossible, the membrane 
should be freely incised and the patient treated as for 
otitis media purulent a acuta. 

CHRONIC MYRINGITIS. 

Chronic myringitis is usually a result of the acute 
form, and is due to the failure of the epithelium to cover 
the raw surface left after the rupture of a bleb or abscess 
in the membrane. This leaves an ulcer which becomes 
covered with granulations, or at times a small polyp. 

Symptoms. — There is regularly a slight discharge. The 
patient may complain of tinnitus, slight deafness and an 
uncomfortable feeling in the ear. 

Diagnosis. — The diagnosis is made upon the appearance 
of the membrana tympani Avhich presents either a granu- 
lating surface or a small polyp, which is not accompanied 
by suppuration of the middle ear. 

Treatment. — ^The indications for treatment are to 
remove the granulations or polyp and bring about der- 
matization of the surface. After anesthetizing the parts, 
the fused bead of silver nitrate is lightly applied; after 
which the area is dusted with boracic acid. If this fails 
to remove the polypoid tissue, it may be taken with the 
sharp ring curette. In cauterizing and curetting these 
areas care should be exercised to avoid perforating the 
membrane. 

TRAUMATIC RUPTURE OF THE MEMBRANA 
TYMPANI. 

Causation. — Rupture of the membrana tympani may 
be produced by direct injury to the membrane, by a 
foreign body or, indirectly, by a change in the air press- 
ure in the external auditory meatus or tympanic cavity. 
Of those ruptured by direct violence, perhaps the per- 
nicious habit, which is far from uncommon, of scratching 
9 



130 DISEASES OF THE MEMBRANA TYMPANI 

the ear with hair pins, ear spoons and various other 
devices, is responsible for the greater number. Next 
in frequency come the attempts to extract a foreign 
body which result in forcing it against the drum head, 
producing rupture. Rarer causes are bullet wounds, 
sword wounds, injury from pieces of steel, etc. Of those 
caused by a change of air pressure, the most frequently 
seen are due to a blow upon the ear which condenses the 
air in the meatus and forces the drum membrane inward 
until rupture takes place. Less conunon causes are 
falls upon the ear, explosions, or the increased air pressure 
encountered by caisson workers and divers. If the mem- 
brane is atr()i)hied, it conduces to ruj)turc. If the Eus- 
tachian tube is occluded or contracted, those causes which 
act through the surrounding atm()s])licrc ])r()ducc a greater 
effect u])()n the mcml)rane. Iiui)turcs from increased 
air pressure within the tympanum usually are caused by 
inflation and are considered under that subject. 

Symptoms. — When rui)ture takes i)lace tlie patient 
usually experiences the sensation of a loud noise. This 
may be followed by vertigo and faintness. Tinnitus and 
mild impairment of hearing may be i)resent. The i)atient 
is aware that something is wrong with the ear and seeks 
advice to ascertain its nature. Occasionally there is 
bleeding, but this is not a common symptom. If infection 
of the middle ear occurs, there will be a purulent discharge 
and symptoms of acute suj)pin'ative otitis media. 

Diagnosis. — The diagnosis is made from the history 
and by seeing the perforation. There is a great variety 
in shape and size of these ruptures, but usually no great 
difficulty is experienced in locating them. If one is in 
doubt auto-inflation or inflation with the catheter leads 
to the production of a whistle or blowing sound, accord- 
ing to the size of the opening. 

Prognosis.^ — Those ruptures caused by condensing the 
air in the meatus or tympanum usually heal without 
noticeable impairment of function. Those produced by 
foreign bodies not infrequently result in middle-ear 



TRAUMATIC RUPTURE OF MEMBRANA TYMPANI 131 

infection and the prognosis becomes less favorable; 
although the suppurative processes following infection 
through traumatic ruptures of the drum membrane are 
usually of milder nature than those which result from 
infection through the Eustachian tube. 

Treatment. — The ruptures which follow condensation 
of the air in the meatus or tympanum require no treat- 
ment as a rule. No harm occurs from syringing the ear 
with bichloride solution 1 to 4000, and this treatment 
may be adopted to prevent infection. These irrigations 
are of decided value in perforations caused by direct 
injury. One feels that in these infection is imminent if 
it has not already occurred. When the opening in the 
drum membrane is healed, if impairment of hearing 
remains, inflation may be of value. 

Medicolegal Considerations. — A few weeks after the 
membrane is healed in many instances it is quite impos- 
sible to determine from the appearance of the drum head, 
not only the location at w^hich rupture occurred, but also 
whether a rupture has been present. So if a patient 
claims to have had a traumatic rupture of the drum mem- 
brane, the surgeon cannot determine, in many instances, 
whether or not the claim is founded on fact. If there is 
no evidence that a perforation has been present, it does 
not prove the patient wrong in his claim. If this evidence 
is found, it is of value only insofar as that it establishes 
that a perforation was present but does not indicate its 
nature. 



CHAPTER V. 

NON-SUPPURATIVE DISEASES OF THE 
MIDDLE EAR. 

In classifying the' non-siippurative diseases of the 
middle ear and Enstachian tube, considerable difficnlty 
is experienced. No classification is perfectly satisfactory. 
They will he discussed from a clinical rather than a 
])ath()logical standpoint, as this will he less confusing to 
the student and give him more (piickly a working 
knowledge. 

TUBAL CATARRH. 

Anatomical. — The Eustachian tube connects tlie naso- 
])harynx with the middle ear. It is al)out one and one- 
half inches in length. Its outer half-inch is osseous, 
and the remaining j)()rti()n is comi)()se(l partly of cartilage 
and partly of fibrous tissue. In a cross-section of this 
part of the tube (Fig. 4()), the cartilage ai)i)ears as a hook, 
it being present on the posterior and upper walls. It 
thus reinforces about one-half of the tube and prevents 
its w\alls from collapsing when acted ui)()n by some external 
force tending to separate them and thus open its central 
canal. The tensor and levator palati muscles are in 
relation with and attached to the tube in such a manner 
that during the act of deglutition when these muscles 
contract, the tube is opened and air from the nasopharynx 
readily passes into the tympanic cavity. This is nature's 
mechanism for maintaining that equilibrium of air pressure 
on the two sides of the drum membrane which is essential 
for its free vibration to occur. 

Causation. — The disease may exist in an ear otherwise 
normal or may occur as part of an exacerbation in chronic 



TUBAL CATARRH 



133 



catarrhal otitis media. The disease is usually caused by 
some catarrhal condition in the nasopharynx. It occurs 
with colds in adults and with adenoids in children. Any 
inflammatory process in the nose or nasopharynx may 
cause it. Sea bathing is responsible for some cases. It 
may complicate any of the infectious diseases, although 
the aural involvement under these circumstances is apt 
to be of a more severe type. 

Pathology. — In tubal catarrh the mucous membrane is 
swollen and contracts the tubal lumen. There is no doubt 
but that swelling and congestion of the tubal mucosa is 




Fig. 46. — Cross-section of Eustachian tube, showing disposition of car- 
tilage in the form of a hook. (Zuckerkandl.) 



the first stage of many middle-ear processes. In an infec- 
tive process of the tympanum, the infection usually travels 
along the Eustachian tube and an inflammation and 
swelling results. In this form of tubal involvement, the 
disease of which it is merely an incident, quickly produces 
symptoms and signs which overshadow those caused by 
the process in the tube. One thinks of the tube as being 
the avenue of infection, but as not being largely concerned 
with the clinical manifestations. When a non-infective 
process invades the tube it may go no farther, the middle- 
ear condition being produced by the mechanical effect 



134 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

of tubal stenosis, in which event there exists the tubal 
catarrh under discussion. In calUng this process non- 
infective, it is desired to signify that an absence of pyogenic 
microorganisms in sufficient number to produce pus is 
meant. It is not known but that some milder form of 
germ may be the cause of the tubal catarrh, or the swelHng 
may be a congestion, perhaps also a collateral edema 
resultant from a neighboring inflammation in the naso- 
pharynx. The swelling and stenosis of the tube prevents 
the interchange of air between the nasopharynx and the 
tympanum, and the air in the middle ear becomes absorbed. 
It is easy to see how the oxygen in the air may be taken 
up by the bloodvessels, the tympanum acting in a manner 
similar to a pulmonary alveolus, liut the condition 
present in many instances leads one to beheve that much 
more than the oxygen content of this iutratympanic! air 
is absorbed. However, the air pressure within the tym- 
panum becomes minus and the pressure on the outside of 
the membrana tympani remaining at that of atmospheric 
air causes the membrane to become depressed, and lose 
its ability to vibrate freely. This produces the signs and 
symptoms of tubal catarrh. 

Symptoms. — The onset of the symptoms may be quite 
sudden or more gradual. The patients usually complain 
of a feeling of fulness or stuffiness in the ear, as though 
the external auditory canal was occluded. Some patients, 
who have had previous experience with impacted cerumen, 
come, asserting that they believe that they have a recur- 
rence of this condition. At times there is tinnitus generally 
of mild degree, although it may be severe and overshadow 
all of the other symptoms. There is regularly impairment 
of hearing which functional tests show to be due to a lesion 
of the sound-conduction mechanism. The elevation of the 
lower-tone limit is not as a rule marked. The upper-tone 
limit is rarely affected. The tuning-fork tests show an 
increased bone conduction, a diminished positive, rarely 
a negative Rinne, with Weber usually lateralized to the 
involved ear if the disease is unilateral. In some patients 



TUBAL CATARRH 135 

there are labyrinthine symptoms, chiefly vertigo, due no 
doubt to increased tension of the labyrinthine fluid caused 
by the stapes being forced into the oval window. Some 
patients are so annoyed by the feeling of pressure in the 
head that mental eft'ort becomes impossible. There can 
be no doubt but that in children with adenoids this 
disease may become a factor in producing their lack of 
mental vigor. 

Signs. — The tympanic membrane is normal in color, 
luster, integrity, and structure. Frequently there is 
injection of the mallear plexus showing as a red streak 
along the manubrium. The position of the drum head is 
altered. It will be found more or less depressed according 
to the duration of the attack and the elasticity of the 
membrane. In some instances the depression of the mem- 
brane is so extreme that it lies in contact with the internal 
tympanic wall. The depression will be readily appreciated 
by the general appearance of the membrane, the fore- 
shortening of the manubrium and b}" the prominence of 
the posterior fold and tympanic ring. 

Diagnosis. — The diagnosis is made from the fact that 
the patient has a feeling of fulness in the ear, tinnitus or 
deafness; that these symtoms have been of short dura- 
tion; that examination shows a depressed drum mem- 
brane otherwise practically normal, and that the middle 
ear is dry, with perhaps other characteristics of the 
inflation sound described under Treatment. 

Prognosis. — Some tubal catarrhs get well in a few days 
or weeks without apparent effect on the function of the ear, 
others take much longer. Some develop tympanic con- 
gestion, while others pass into a chronic state and become 
a factor in the development of chronic catarrhal otitis 
media. 

Treatment. — The treatment consists in catheteriza- 
tion and attending to the condition of the Eustachian 
tube and nasopharynx. Upon inflation the tympanic 
membrane frequently goes back into place with a distinct 
snap or thud. If this occurs upon the first gentle pressure 



136 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

of the bulb, it is fair to assume that the tubal swelling 
is at the pharyngeal orifice, and that the point of the 
catheter has passed beyond it. If the tumefaction is 
farther along the tube, air may not pass through until 
after the bulb has been compressed two, three or even 
more times. Its passage may then he accompanied by a 
high-pitched note, at times a whistle, subsequent blasts 
requiring considerable pressure on the bulb to force air 
through. At times inflation seems to dislodge a plug of 
tenacious mucus. When this is the case, subsc(|uent 
air blasts are more free. Inflation is to be repeated daily 
or every second day until the tube remains open. Usually 
immediately after inflation the i)aticnt experiences con- 
siderable relief, exceptionally he feels as bad or slightly 
worse. This will be due to the fact that, owing to the 
narrowness of the tube, the air forced into the tympanum 
cannot return, and there is thus produced increased 
pressure with bulging of the drum membrane. This will 
pass away in an hour or so with a sensation of relief from 
pressure and improvement of hearing. Ai)i)lications of 
argyrol, 25 per cent., or silver nitrate, 2 to 4 i)er cent., are 
to be made to the mouth of the tube and nasopharynx. 
The use of cocaine for these inflations seems to diminish 
tubal engorgement, acting directly when a])])lie(l to the 
tubal orifice with the ai)plicat()r, and indirectly through 
its action on the vessels of the inferior turbinate which 
are intimately connected with those of the tube. In 
stubborn cases applications of cocaine followed by argyrol 
or nitrate of silver solutions may be made directly to the 
tubal mucosa, by inserting a cotton-tipped applicator 
through the Eustachian catheter. These applicators 
may be bought in the shops, or a very useful one may be 
made from No. 5 piano wire, as suggested by Dr. Dench.^ 
The wire is roughened at the end so that the cotton may be 
firmly retained. It is then passed through the catheter, 
which is to be used, until it projects one and one-half 

^ Diseases of the Ear, third edition, p. 313. 



TUBOTYMPANITES 137 

inches beyond the tip and the wire bent at a right angle 
at the ring end. This gives the measurement be^^ond which 
it is not safe to pass the apphcator. Having inserted the 
catheter and ascertained that it is in position, the apph- 
cator, armed with a small and firmly wound cotton tip, 
which has been saturated with the desired solution, is 
passed through the catheter into the tube. The patient 
is requested to swallow as any obstruction is encountered, 
as this opens the tube and allows the applicator to be 
passed more easily. In patients showing a tendency to 
repeated attacks of tubal catarrh, the nose and naso- 
pharyngeal condition should be attended to, enlarged 
posterior tips of the inferior turbinate snared or any other 
abnormal condition corrected, and the adenoids should 
be removed in children. 

TUBOTYMPANITES (TUBOTYMPANIC CONGESTION). 

Causation. — The causation is the same as in tubal 
catarrh, as it usually follows the latter disease, especially 
if proper treatment has not been promptly instituted. 

Pathology. — In tubotympanites, in addition to the 
changes in the Eustachian tube, characteristic of tubal 
catarrh, there is also congestion of the tympanic mucous 
membrane. This condition leads to a serous effusion 
or increase of mucus, so that it becomes evident upon 
inflation. The changes in the mucous membrane of the 
tympanum may be in the nature of a passive congestion. 
When this exists it may be fairly attributable to the 
diminished intratympanic pressure which has been 
brought about by the tubal occlusion. This venous con- 
gestion is followed by the transudation of serum, which 
may fill the tympanic cavity more or less completely. 
The condition of the bloodvessels associated with chronic 
renal, cardiac or hepatic disease, may aid in bringing 
about this result. In the second form the congestion in the 
mucous membrane of the middle ear is an extension of 
the process in the tube, and not directly caused by the 



138 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

change in intratympanic air pressure and the effusion 
is of a more mucoid character. While these two types 
may sometimes be separated clinically, no attempt to do 
so will be made in the present discussion. After the 
mucous membrane in the tympanum becomes swollen 
and fluid transudes, the minus intratympanic pressure 
is relieved and the drum head may return to its original 
position. The swelling of the tubal mucosa or the accumu-^ 
lation of tenacious mucus within the tube may so inter- 
fere with the drainage of the mucus, or serum may 
accumulate in sufficient quantity to produce a mild 
increase in the pressure within the tympanum, but never 
to the same degree as in active middle-ear inflammation. 
In fact, the instances in w^hich it is possible to recognize 
this increased pressure by signs and symptoms are 
uncommon and may be considered as on the border-line 
of acute catarrhal otitis media. The disease is usually 
of an acute or subacute nature. 

Symptoms. — There is a feeling of fulness and stuffiness 
in the ear and discomfort in the head, but usually absence 
of pain at least severe in degree. Exceptionally, the 
patient describes his sensation as being one of pain, but 
upon careful inquiry it is found not to be like the severe 
pain of acute intlannnation which keeps the patient awake 
at night. However, the dividing line l)etween the acute 
type of tubotympanic congestion and the mild form of 
acute catarrhal otitis media may at times be hard to 
place as regards the pain. Still, pain even of mild degree 
may be considered the exception in tubotympanites. 
There is always some impairment of hearing, the degree 
depending to a certain extent upon the amount and loca- 
tion of the fluid. When this is excessive so that the oval 
and round windows are covered, the deafness is quite 
marked. When the fluid is less in amount, the impairment 
of hearing is often increased when the head is inclined 
backward or the patient lies on his back. In this position 
the fluid accumulates in the region of the labyrinthine 
windows. With the head inclined forward relief may be 



TUBOTYMPANITES 139 

experienced as the fluid gravitates away from the fenestrse. 
There is increase in bone conduction varying with the 
degree of the impairment of hearing. This gives rise to 
positive Schwabach and Weber tests, with a diminished 
positive, rarely a negative Rinne. The lower-tone limit is 
apt to be elevated but the upper-tone limit remains normal, 
unless there are labyrinthine changes which are not a part 
of this disease. A frequent symptom is a distressing click 
heard upon swallowing, due to the effect upon the fluid 
within the tympanum produced by nature's attempt to 
open the Eustachian tube. Autophony is at times an 
annoying s^-mptom; the patient's own voice has an un- 
natural sound, as though he was talking with his head in 
a barrel. Tinnitus is also a common symptom. Some of 
these patients complain of a feeling as though something 
was moving in the ear. This is due, no doubt, to changes 
in the position of the fluid within the tympanum. There 
is usually no rise of temperature. If fever is present and 
due to the aural condition, one may feel quite positive 
that it should be classed as an acute inflammation of the 
middle ear and not as tubotympanites. 

Signs. — Upon inspecting the membrana tympani the 
luster is usually normal. The color may be normal or of a 
yellowish tinge from the serum showing through, or of a 
dull bluish color. Upon closer inspection the latter color 
is found to be due to venous engorgement, the vessels 
at times showing quite plainly throughout the membrane. 
The manubrial and peripheral plexuses may be injected 
and red, but this bluish appearance of the membrana tensa 
is characteristic and is probably present in the early stages 
of this disease in the majority of instances. The engorge- 
ment of the drum head mucosa, to which this appearance 
is due, clears up more rapidly than that of the rest of the 
tympanum, so that when the patient comes under obser- 
vation this appearance of the drum membrane may be 
absent, although it is not infrequently seen. When the 
fluid in the middle ear is considerable in amount, it is 
possible at times to determine its level which is marked 



140 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

by a transverse line, and after inflation the membrane 
below this line may be studded with little spots in motion 
which are really bubbles in the intratympanic fluid. 
The student must not be disappointed if he sees this but 
seldom, as it is not usually noticeable. The drum mem- 
brane may be normal hi position, slightly retracted or the 
retraction may be less than normal. Bulging is of very 
uncommon occurrence. While its possibility cannot be 
denied from the conception of the disease as above stated, 
still its occurrence would lead one to doubt that the 
process in which it was present really belonged to this 
class. Upon inflating with the catheter there is a bubbling, 
crackling sound either as the air is blown through or 
immediately following this, when the pressure upon the 
bulb is relaxed. This sound is heard as though located 
in the examiner's ear, and must not l)e confused with 
rales produced at the pharyngeal orifice of the tube, 
which gives one the imi)ressi()n as of coming from outside 
of the ear. Occasionally these will be i)resent in addition 
to the intratympanic crackling, and are due no doubt to 
the presence of the fluid which has been forced out of the 
ear by the air blast. 

Diagnosis. — The sound of crei)itation or crackling from 
the intratympanic fluid is characteristic, and establishes 
the diagnosis if sui)purative i)r()cesses with fluid within 
the tympanum and the exudative form of chronic catarrhal 
otitis media can be excluded. From the former the 
diagnosis is made by the absence in tul)otympanites of 
pain or fever, and the absence of the changes in the 
tympanic membrane which are found in the acute middle- 
ear inflammations. From the exudative type of chronic 
catarrhal otitis media the diagnosis may be extremely 
difficult. When the drum membrane presents the bluish 
appearance characteristic of the early stages of tubo- 
tympanic congestion, this establishes the diagnosis. The 
element of time may also be considered, this disease being 
essentially acute or subacute. The feeling of fulness or 
stuflfiness in the ears is more often complained of in tu})o- 



TUBOTYMPANITES 141 

tympanites, while in chronic catarrhal otitis media the 
patient more often complains of deafness. If tubo- 
tympanic congestion arises in a patient suffering from the 
hyperplastic form of chronic catarrhal otitis media, or 
having existed results in the exudative form, the diagnosis ■ 
may be impossible with any degree of certainty. It is 
probable that there is no hard-and-fast line between 
the subacute form of tubotympanic congestion and the 
exudative form of chronic catarrhal otitis media, and as 
treatment is the same in either case it may be necessary 
to leave the diagnosis in doubt. 

Prognosis.— This disease may result in cure with very 
slight or moderate deafness, or changes may take place 
in the mucous membrane of the middle ear of a more or less 
permanent nature, so that when the attack passes off 
and the ear is dry the patient may have chronic catarrhal 
otitis media of the adhesive or hyperplastic type, or the 
tubotympanities may become chronic, resulting in the 
exudative type. 

Treatment.— The indications for treatment are to remove 
the fluid and to restore the mucous membrane as far as 
possible to a normal condition. These indications are 
best fulfilled by inflation performed every second or third 
day, followed by the application of nitrate of silver solu- 
tion, 2 to 4 per cent., to the mouth of the tube and naso- 
pharynx. In this disease the use of nitrate of silver seems 
to be of more value than argyrol; however, the latter may 
be applied through the catheter, as advised in tubal catarrh. 
Stimulating vapors will be found of value in these patients. 
The following formulae are suggested: 

I^ — Tr. iodini . . . 5ss I^ — Menthol, 

Chloroformi, Camphor . . aa 3J 

Alcoholis . . aa 5J— M Tr. iodmi . . 5J— M 

A few drops of one of these solutions is placed upon 
cotton contained in the rubber bottle attached to the 
inflating apparatus and the stopper turned so that, as the 
air passes through the bottle, it becomes impregnated 



142 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

with the vapor of these volatile substances and thus carries 
the medication into the tympanum. In many patients 
after treatment, the condition clears up and the ear be- 
comes dry. In some the process seems quite stubborn. At 
times the patient will cease attending for a few weeks and 
return with a dry middle ear. So if treatment produces 
no effect after a fair trial, a rest may be advised. As a 
last resort, the tympanic membrane may be incised, after 
which the fluid is driven out of the tympanum through the 
opening by inflation or through the Eustachian tube by 
the otoscope. It would seem that this procedure ought 
to give relief, but it seldom produces permanent improve- 
ment. The fluid is apt to reaccunuilate, and the perfora- 
tion heals, leaving the patient no better than before, or 
infection may occur and the disease become of a suppura- 
tive nature. It is possible that tliese i)atients are more 
susceptible to suppurative otitis media than others, and 
that infection through the tube may cause this condition. 
Some aurists believe tliat inflation may be a menace for 
this reason. Experience teaches that this belief is without 
foundation, as a careful inflation, skilfully performed, very 
rarely, if ever, gives rise to infection. Everything possible 
should be done to improve the general health and to relieve 
any abnormal condition of the nose or nasopharynx. 



OTITIS MEDIA CATARRHALIS CHRONICA (O. M. C. C.) 
(CHRONIC CATARRHAL OTITIS MEDIA). 

Chronic catarrhal otitis media, or O. M. C. C, as it is 
usually called by aurists, is a chronic affection of the 
mucous membrane of the tympanum and Eustachian 
tube. The change in the mucous membrane may be in 
the nature of an engorgement and consequent thickening 
with an excess of secretion, the exudative type, or there 
may be formation of connective tissue in the form of 
diffuse thickening, adhesions or bands. This is called the 
hyperplastic or adhesive type. While the division of 



OTITIS MEDIA CATARRHALIS CHRONICA 143 

0. ]M. C. C. into the exudative and hyperplastic types 
is open to considerable criticism, still it answers very well 
and is about the only clinical division that can be made 
that is based upon the pathological conditions. The word 
''exudative'' is used to indicate an increase of moisture 
within the tympanum without regard to the manner of 
its production. This, as will be shown, may be a transu- 
dation of serum, or an increased secretion of mucus, so 
in speaking of this type as an exudative catarrh, while 
the word is not strictly correct in a pathological sense, 
it is nevertheless convenient when used in this way by 
clinicians. 

Exudative Type of Chronic Catarrhal Otitis Media.— 
The clinical characteristic of this type is a transudation 
of serum or the secretion of mucus on the surface of the 
tympanic mucous membrane in sufficient quantity to be 
detected upon catheterization. If the fluid is less in 
amount than this, there are no means by which this type 
may be separated clinically. 

Causation.- The disease ma}^ originate from a naso- 
pharyngeal catarrh or may occur, when this is absent, 
without known cause. Chronic catarrh of the Eustachian 
tube is frequently responsible for it, or it may arise from 
tubotympanic congestion. Adenoids is an important 
factor in many instances. Nasal obstruction and enlarge- 
ment of the posterior end of the lower turbinates seem to 
exert a causative influence. 

Pathology. — The mucous membrane is swollen and 
engorged as a result of diminished intratympanic pressure, 
or from an extension of a similar condition in the 
Eustachian tube, or the process may originate in the 
mucous membrane of the tympanum. It is evident that 
there may be one of two processes in the mucosa: (1) 
a passive congestion with the transudation of serum or 
sero-mucus; (2) for lack of a better name, may be 
called a catarrhal process, which is accompanied by 
increased blood supply with thickening of the mucous 
membrane and increased production of mucus. These 



144 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

processes are essentially chronic in nature, and may or 
may not be associated with hyperplastic changes; but if 
they continue to exist unrelieved, they are almost certain 
to result in the production of connective tissue in the form 
of diffuse thickening, adhesions or bands. Or the exudation 
may be developed in an ear which is already the seat of 
the hyperplastic form of O. M. (\ C. However this 
may be, the fluid contents of the tympanum, while not 
necessarily causing the sym])t()ms, enable one to establish 
this form of otitis media. 

Symptoms. — Deafness is a constant symptom of this 
disease. The degree of iin])airmcnt of hearing is not 
usually as extreme as in the hyperplastic type, unless 
the fluid exists in sufficient quantity to cover the oval 
and round windows, when it may be (|uite profound. 
While the deafness may be due to the (hiid to a greater 
or less degree, it is at least partially caused by changes 
in the mucous membrane which, while it becomes less 
I)Hal)le tlian normal, never assumes the rigidity which is 
present after hyperplastic changes have taken place. 
There is an elevation of the lower-tone limit, an increased 
bone conduction, giving rise in persons under fifty to a 
positive Schwabach and Weber, with a negative or 
diminished i)()sitive Rinnc. Subjective noises are apt 
to be a prominent symptom. The patient complains of 
roaring, rumbling sounds. They are usually of lower 
pitch than in the hyperj)lastic tyi)e. There may be a 
feeling of fulness in the head, and the i)atient is apt to be 
nervous and disinclined to mental effort. Autophony 
is sometimes complained of. Pain is not present, but the 
distressing feeling in the head of which these patients 
sometimes complain is no doubt harder to bear than acute 
pain would be. 

Signs. — The drum membrane may be depressed. It may 
also appear to have a yellowish tinge from the fluid in the 
tympanum. This may also produce a line marking the 
fluid as described under Tubotympanites. The luster is 
usually normal and the structure not altered. The drum 



OTITIS MEDIA CATARRHALIS CHRONICA 145 

membrane more often than otherwise is practically 
normal in appearance. Upon inflation the tube may be 
found more or less stenosed, either on account of the 
swelling of the mucosa or the presence of tenacious 
mucus. This is sho\\ai by the fact that the air passes 
less readily tlirough the tube, requu^ing greater pressure 
upon the bulb, or only passing thi^ough upon the second or 
subsequent compressions. Before the air enters the middle 
ear an auscultation sound, due to its impact upon the 
mucus contained within the tympanum, may sometimes 
be heard. This is a clicking sound followed by a murmur 
which gives one the impression of coming from outside 
the inflator's ear. This element of distance shows that 
air does not enter and circulate within the tympanic 
cavity. As the air enters the middle ear, two varieties 
of sound may be interpreted as being caused by intra- 
tympanic fluid. The first when the fluid is small in amount 
and tenacious, which causes opposed surfaces of mucous 
membrane to adhere. As the air blast enters these are 
separated and a high-pitched sound is produced. It is of 
short duration and only heard upon the entrance of the 
air. The murmur that follows is usually dry and varying 
in pitch, with the lumen of the tube. The second occurs 
when the fluid is more considerable in amount and is a 
crackling, bubbling, crepitation sound which presents 
considerable variation in different patients. The sound 
occurs either while the bulb is being compressed or after 
relaxing the grip, and is due to air being forced through 
the fluid. A certain amount of knowledge concerning the 
character of the fluid may be derived from a study of these 
sounds. It is presumed that a considerable part of the 
crepitation is produced by the rupture of the bubbles 
which the air produces in this intratympanic fluid. This 
being so, the finer the crepitation sound, the less viscid 
the fluid, that is the more serous; while the coarse sounds, 
and especially those delayed until after the bulb is relaxed, 
indicate a greater viscosity of the fluid and therefore a 
greater mucus content. 
10 



146 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

Diagnosis. — The diagnosis of this type of O. ]M. C. C. 
from tubotympanic congestion, which it greatly resembles 
in many respects, has been discussed under the latter 
disease. That it is a form of O. ]\1. C. C. is determined 
by the presence of chronic deafness, due to a lesion of 
the sound-conducting mechanism and not associated with 
any of the fundus changes of a purulent otitis media, or 
its residual processes. From the hyperplastic or adhesive 
type it is separated by the characteristic auscultation 
sounds. When the two processes are associated in the same 
patient, it may be impossible to determine how much of the 
deafness is due to the exudative and how much to the 
hyperplastic type. The only data from wliich one may 
draw a conclusion are the amount of imi)rovement in 
hearing after inflation, which is usually greater in the 
former type, and the increase in hearing when b}' treat- 
ment the aural condition improves so that the character- 
istic auscultation sounds disappear, the greater the 
improvement, the greater the probability that the process 
was of the exudative type. These data, it must be con- 
ceded, are uncertain, as some thickening of the tympanic 
mucous membrane, not due to hypcri)lastic changes, may 
be left after the fluid has disaj)peared and be productive 
of a certain amount of imi)airment of hearing. When 
there is exudative catarrh and the fluid does not exist in 
sufficient amount to give the characteristic auscultation 
signs, or is so located that it does not do so, there are no 
means by which such a condition can be diagnosed from 
the hyperplastic type. 

Prognosis. — The prognosis, while uncertain, is decidedly 
better than in the hyperplastic or dry form. Many 
patients are benefited by treatment. Those processes 
resulting from tubal obstruction are perhaps the most 
favorable. It must be remembered that the adhesive 
type may result from the exudative, and if the changes 
are in certain locations, marked deafness may result. So 
while encouraging the patient to hope for amelioration, 
the prognosis should be quite guarded. 



OTITIS MEDIA CATARRHALIS CHRONICA 147 

Treatment. — In treating this condition the indications 
are to remove the fluid and to reHeve the underlying 
condition in the tympanum and tube. The best way to 
meet these indications at present known is by inflation 
through the catheter. The fluid is, under favorable con- 
ditions, at least partially forced out through the tube; 
the increased intratympanic pressure produced by infla- 
tion tends to lessen the congestion; and the stretching of 
the tube has a tendency to diminish the engorgement 
of its mucosa. Inflation should be performed every two 
or three days, for a few weeks, then less often. No rule 
can be given, but the progress made will indicate when 
inflation should be done less frequently. The vapors, 
advised under tubot^^mpanic congestion, have a favorable 
action both in stimulating the mucous membrane to 
absorb the fluid and in bringing it into a healthier con- 
dition. The mucous membrane in the pharyngeal orifice 
of the tube should be anesthetized with a solution of 
cocaine, or if some other anesthetic is used which does 
not produce contraction of the mucous membrane, it is 
to be followed by the application of one of the preparations 
of the suprarenal capsule, such as adrenalin, passed well 
into the tubal orifice to produce contraction, as far as 
possible, of the tubal mucosa. Then after inflation an 
application of 2 to 4 per cent, of silver nitrate is made well 
into the tubal orifice with a curved applicator. If deemed 
advisable on account of the persistence of the swelling 
of the tubal mucosa, as shown upon catheterization, 
applications of cocaine followed by argyrol or silver 
nitrate may be made throughout the length of the tube, 
as described under Tubal Catarrh. The injection of fluid 
through the catheter into the middle ear, as advised by 
some, does not appeal to the author as being a perfectly 
safe procedure. Tenacious mucus is the most difficult 
to deal with by inflation. An incision may be made in the 
membrana tympani and the fluid forced out through the 
opening. This may be successful in some instances, but 
too much must not be expected from this mode of treat- 



148 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

merit. Any existing abnormality of the nose or naso- 
pharynx should be relieved if possible. If adenoids are 
present, their removal may, and usually does, result in 
improvement. In other abnormal conditions which may 
be found, while their correction is the proper procedure, 
too much hope of relief of the aural condition should not 
be encouraged. One is continually being consulted by 
patients who have submitted to an operation on some nasal 
or pharyngeal condition, l)eing encouraged thereto by 
the assurance that aural improvement would result, and 
who have been (lisai)p()inted in finding that their faith 
has not been justified by the results. For the noises in the 
head which these patients experience, in addition to the 
treatment outlined above, the bromides in bVgrain doses, 
three times a day, are as good as any internal medication. 
The general health should receive attention and constipa- 
tion relieved, especially if tinnitus is present. 

Hyperplastic or Dry Type. Adhesive Catarrh. — The 
hyperplastic or adlicsi\e type of chronic catarrhal otitis 
media is a common disease and much more frequently seen 
than the form accompanied by fluid in the tympanum. 

Causation. — The causes of (). M.(\(^. are frecjuent 
attacks of tubal catarrh or tubotympanic congestion; 
catarrhal processes in the nasopharynx; hereditary 
predisposition, although if this is marked it favors the 
diagnosis of otosclerosis; frequent colds, bad climatic con- 
ditions and unhygienic surroundings. 

Pathology. — The pathological condition is the formation 
of new connective tissue. This may occur in the form of 
diffuse or localized thickening, in adhesions between the 
various intratympanic structures or in bands. If any of 
these conditions exist and do not produce deafness, the 
notice of tlie aurist is not directed to them. In order to 
produce deafness some interference with the transmission 
of sonorous vibrations from the drum head through the 
ossicular chain to the labyrinthine fluid must be present, 
or there must be some loss of motility of the membrane 
closing the round window, as these are the avenues through 



OTITIS MEDIA CATARRHALIS CHRONICA 149 

which sound reaches the labyrinthine fluid and perceptive 
mechanism. According to location, the lesions may be 
divided into four groups: 

1. Those which interfere with the motility of the 
membrana tympani: (a) processes causing contraction of 
the Eustachian tube operating as in tubal catarrh; (6) 
adhesions between the drum membrane and the internal 
tympanic wall; (c) more rarely the drum head itself may 
be thickened and its motility thereby impaired. 

2. Lesions interfering with the motility of the ossicular 
chain: (a) adhesions between the handle of the malleus 
and internal tympanic wall; (6) adhesions or bands 
between the malleus and incus and the tegmen tympani; 
(c) ankylosis of the joints between the malleus and incus 
or between the incus and stapes; (d) adhesions between 
the long process of the incus and the internal tvmpanic 
wall. 

3. Lesions interfering with the motility of the stapes: 
(a) adhesions or bands between the crura and the walls 
of the niche of the oval window; (b) thickening of the 
mucous membrane around the foot-plate; (c) deposit 
of lime salts in the annular ligament. 

4. Lesions interfering with the motility of the membrana 
tympani secondaria: (a) thickening of the mucous mem- 
brane; (6) bands and adhesions in the niche of the round 
window. There are great variations both in the location 
of the lesions and the degree of their development. 

The tympanum contains many folds of mucous mem- 
brane, and for normal hearing their perfect pliability is 
necessary. Even a slight thickening and rigidity of these 
folds interferes with the proper transmission of sonorous 
vibrations. 

Symptoms. — Deafness is a constant symptom. Its 
degree varies greatly. Some patients are unaware of its 
presence either because it is unilateral, or on account of 
its being so slight. The amount of hearing possessed 
by the normal ear is largely in excess of the requirements 
of daily life in the ordinary vocations; so the patient only 



150 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

discovers that he is deaf when some extraordinary demand 
is made upon his hearing power, or when led by the 
occurrence of tinitus he seeks advice and it is discovered 
by the aurist. Others when coming under observation 
are profoundly deaf so that they cannot hear ordinary 
conversation even in their immediate proximity. Between 
these two extremes are al) grades of deafness in patients 
presenting with the adhesive form of O. iVI. C. C. The 
deafness may progress slowly or remain stationary for 
periods of time. Some i)atients get worse only after 
attacks of tubal catarrh or tubotympanic congestion,' 
each attack leaving them with a Httk^ more impairment 
of hearing, perhaps also more tinnitus than before, while 
during the attack the deafness is considerably increased. 
When one ear is involved the opposite ear is more apt to 
become affected than in a nornud individual. When the 
deafness in one ear becomes quite marked and then the 
other ear becomes involved, it commonly occurs that the 
disease in the second ear progresses more rai)i(lly than in 
the first ear to become affected, so in a varying time the 
ear last involved becomes the deafer of the two. A 
symptom sometimes present when the deafness is quite 
marked is known as paracusis Willisii. Patients with 
this symotom hear better in the presence of a loud noise. 
For example, while riding in the subway or in a noisy 
street they can hear conversation which in a quiet place 
would be impossible. The explanation of this symptom 
is that the intense sonorous vibrations produced by the 
loud noises, set in vibration the stiffened conductive 
mechanism and in this condition it more readily responds 
to the gentle waves of the conversational voice. There is 
regularly an elevation of the lower-tone limit, varying 
usually with the degree of impairment of hearing. The 
deafer the patient, the more the limit is elevated. Lowering 
of the upper-tone limit sometimes occurs from extension 
to the labyrinth. If this is at all marked it favors the 
diagnosis of otosclerosis. There is increased bone con- 
duction becoming, if deafness is marked, greater than air 



OTITIS MEDIA CATARRHALIS CHRONICA 151 

conduction (with 256 D. V. fork B. C. +, B. C. > A. C. 
Weber + to deafer ear) . 

The subjective head noises are of almost endless variety 
and intensity. They are, however, apt to be worse than 
in suppurative processes or even than in the other forms 
of non-suppurative middle-ear disease. These patients 
frequently complain of '^shooting" pains in and around the 
ear. These pains are intermittent and not to be compared 
in severity with those which are produced by acute 
middle-ear inflammation. The strain under which patients 
with severe deafness labor is frequently very apparent 
both in their facial expression and in their manner. They 
watch one^s lips closely, thereby being aided to a knowl- 
edge of one's conversation that the hearing alone could 
not give. Some patients are very sensitive about their 
infirmity and resent one's speaking to them in a loud 
voice. INIany, no doubt, can hear better if the voice is 
not so loud, but the articulation distinct. Vertigo is 
sometimes a symptom and indicates that there is some 
disturbance of the labyrinth — a change in the labyrinthine 
structures or circulation; or in the pressure of the fluid 
within the labyrinth. 

Signs. — The luster of the membrana tympani is either 
normal or but slightly diminished. The color is never red, 
but is normal or whiter than normal. The integrity is 
unimpaired. If any changes exist they are in the structure 
and position. These structural changes show as opaque 
spots or plaques or involve the whole membrane, or the 
membrane may be thin and transparent from atrophy, 
allowing the color of the pink mucous membrane on the 
internal tympanic wall to show through, and the long 
process of the incus articulated with the stapes to be seen. 
The drum head will be depressed if the Eustachian tube 
is stenosed or the membrane has been relaxed through 
stretching from former stenosis. The same result may be 
brought about by adhesions which bind the membrane 
or the handle of the malleus to the internal tympanic wall. 
One quite characteristic appearance of the drum membrane 



152 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

is due to depressed areas. They at times very closely 
resemble old perforations which have been closed with thin 
cicatricial tissue. These areas are caused by atrophy of the 
membrane associated with long-continued minus intra- 
tympanic pressure. At times the cicatricial bands in the 
tympanic cavity have resulted in rotation of the malleus. 
If this ossicle is turned so that the short process points 
more forward than normal, the manubrium will appear 
broadened; if rotated so that it points more posteriorly 
than it normally does, it will a])pcar narrower. 

Inflation. — Inflation may show that the luistachian 
tul)e is in any degree of patency. When very narrow, the 
tubal constriction is not as easily overcome as in acute 
tubal catarrh. It may require considerable force to 
overcome the obstruction, and the air enters the 
tympanum in small ([uantity witli a rather high-i)itched 
murmur throughout the inflation, although at times 
toward the latter part it may enter more freely with a 
somewhat lower-])itched murmur, showing that some of 
the constriction is due to engorgement of the tul)al mucosa, 
although most of it is caused })y hyi)er])lastic changes. 
On the other hand, the tube may be of abnormal patency, 
giving a low-pitched murmur with the impression of 
abundance of air passing through the tympanum. The 
sound produced by vibration of the drum head may be a 
dull thud, showing that it is not noticeal)ly relaxed; or 
there may be a shar]) snap, showing relaxation of the mem- 
brane. This high-pitched snap is more often found when 
the depressed areas alluded to above are present. Con- 
siderable discussion has taken place in recent years as 
to the effect on the drum head of what has l)een termed 
'"overinflation," some otologists claiming that this 
relaxed membrane which moves out with a distinct snap 
is due to "overinflation." While it cannot be doubted 
that frequent inflations by Valsalva's method may be 
harmful by causing a congestion of the head and ears, 
perhaps also some relaxation of the drum membrane, there 
appears to be very little in this ''overinflation'' theory 



OTITIS MEDIA CATARRHALIS CHRONICA 153 

as the cause of these relaxed drum membranes. The 
author has under observation at the present time patients 
who have been inflated regularly for years, whose drum 
membranes are not abnormally flaccid, and others are 
constantly coming under observation who have never 
been inflated and yet present these relaxed membranes. 
The force producing them is not "over inflation," but long- 
continued minus intratympanic pressure, aided no doubt 
in many instances by atrophic or degenerative changes in 
the membrane itself. 

Diagnosis. — The diagnosis of the hyperplastic or adhe- 
sive type of O. M. C. C. rests on the following consid- 
erations: The presence of chronic deafness which tests 
show to be due to involvement of the sound-conducting 
mechanism; the appearance of the drum membrane being 
practically normal in color, luster and integrity (for excep- 
tions, see Signs); and by inflation demonstrating a dry 
middle ear. The diagnosis from otosclerosis will be con- 
sidered under that disease, while the separation of this 
type from the exudative type has already been considered. 

Prognosis. — The prognosis of this form of O. M. C. C. 
cannot be regarded as favorable insofar as the hearing is 
concerned. Some patients are improved to a moderate 
degree; others, perhaps to a certain extent on account of 
treatment, remain stationary, while many, no matter what 
treatment is adopted, become progressively worse. 

Treatment. — The treatment cannot be regarded as 
satisfactory. While a great deal may be done for these 
patients and many improve, still in spite of all of one's 
efforts some remain stationary or even get worse. Those 
patients in whom involvement of the Eustachian tube 
increases the deafness generally experience most benefit. 
In this class it is usual to have increased hearing after 
inflation, or if the tube is so constricted that the air 
cannot return but produces increased pressure in the 
tympanum, the improvement occurs within an hour or so, 
as the pressure becomes equal on both sides of the drum 
membrane. In either event it is fair to assume that part 



154 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

of the deafness is due to lack of motility of the drum 
head from minus intrat\ mpanic pressure, and improve- 
ment by treatment may be expected if the tubal condition 
can be relieved. An attempt to accomplish this is made 
by inflation repeated every three days, and the application 
of argyrol or silver nitrate to the mouth of the tube 
or to the tube itself after the inflation (see Tubal Catarrh). 
In patients with marked tubal stenosis good results are 
often obtained from the use of whalel)()ne bougies (Fig. 
47). The catheter is first introduced and inflation per- 
formed. This establishes the fact that the catheter is 
in the mouth of the tube. Then the smaUest-sized bougie 
is passed through the catheter to a depth of one and one- 
quarter inches. It is allowed to remain a few moments, 



TIEMANN 

Fig. 47. — Author's whiilebone bougies. 

then the next size, and so on until the largest size that will 
pass through the constriction has been used. The patient 
is not to be inflated for three or four days on account 
of the danger of emphysema. This procedure may be 
repeated every ten days or two weeks, until the inflation 
sound shows improvement. It not rarely results in some 
relief from the tinnitus which may be present. In patients 
who have a complicating acute tubal catarrh or tubo- 
tympanites, the attack of these diseases is to be treated 
until relieved to prevent added impairment of hearing. 
To those patients who get worse by repeated attacks 
of these diseases, the aurist becomes of real value. He 
treats theni through these attacks and preserves the hear- 
ing for years, in some instances without allowing much 
added impairment to take place. In patients in whom 



OTITIS MEDIA CATARRHALIS CHRONICA 155 

the lesion is not in the tube very httle or no improvement 
occurs after one inflation; nevertheless some of these 
patients will improve if inflated twice a week for a month 
and once a week thereafter. It may be found after several 
months that they are better. It is impossible to tell 
beforehand which ones will improve. Then in others 
it is possible that the disease is held in check by the mas- 
sage of the middle-ear structures aft'orded by inflations. 
Patients are seen who with faithful treatment remain 
stationary for years, then becoming discouraged at their 
non-improvement, they cease to attend and grow worse 
rapidly. The number who give this history is too consider- 
able to attribute it to chance. Vibrations and massage 
with various sorts of apparatus, such as the otoscope, 
Delstanche's masseur, electric and pneumatic apparatus, 
have been tried and recommended by some, but they are 
all of slight value as compared with inflation by the 
catheter. For the noises the bromides may be given a 
trial in addition to the other treatment. The care of the 
general health is not to be neglected. Various operations 
have been performed upon the ear with a view to increasing 
the hearing. Formation of an artificial opening in the 
drum membrane may produce temporary improvement 
in proper cases, but the opening usually soon closes and 
the condition becomes as before. The stapes has been 
removed, but the scar tissue forming in the niche of the 
oval window during healing is apt to result in greater 
impairment of hearing than before, if the patient escapes 
total deafness from labyrinthine inflammation. Removal 
of the malleus and incus together with the drum membrane 
has had its advocates. There can be no doubt but that 
temporary improvement may be produced by this pro- 
cedure in properly selected patients, but in the majority 
of them during the healing process the mucous membrane 
becomes thickened and the patients' hearing returns to 
its former condition. These operations are quite fascinat- 
ing, but to the conscientious surgeon are apt to be dis- 
appointing. Still, if the patient wants something more 



156 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

done after stating the case to him the surgeon is justified 
in undertaking them. The operation of removing the 
malleus and incus for the rehef of deafness is practically 
the same as when this operation is performed for the 
relief of chronic suppuration (see Ossiculectomy, page 2()9) ; 
the only difference being that there are no granulations 
to remove and that any bands or adhesions in the niches 
of the oval and round windows arc to be incised. 



OTOSCLEROSIS, OSTEITIS METAPLASTICA. 

The term ''otosclerosis" was applied to a form of 
deafness due to lesion of the conducting mechanism before 
the true pathology of tlic disease was thoroughly known, 
and since it has l)ccn demonstrated that it is not a sclerotic 
process the name has been retained. It is usual to discuss 
otosclerosis under the non-sn])])urative diseases of the 
middle ear, but it is as much in j)lacc under the non- 
suppurative diseases of the labyrinth, as in its clinical 
history it presents forms which closely resemble both of 
these classes of disease. 

Causation. — Practically nothing is known of the causa- 
tion of otosclerosis, except that in some instances an 
hereditary influence seems quite marked. One, however, 
sees patients with this disease in whom the clos(?st 
questioning fails to obtain any history of the occurrence 
of deafness in any members of their family, near or 
remote. It has been found that syphilis and childbirth 
have a tendency to increase the rai)i(lity of the progress 
of the disease, but it is not believed that they exert in 
any way an etiological influence. Several theories have 
been advanced to account for its occurrence, but they 
are not much more than the merest speculation. It has 
been found with slightly greater frequency in females 
than in males. It may occur at any age. Manasse^ has 

1 Arch, fiir Ohrenheilk., vol. xov, p. 45. 



OTOSCLEROSIS, OSTEITIS METAPLASTICA 157 

found it in temporal bones of children as young as three 
years, and it probably occurs earlier in life, perhaps 
in utero. 

Pathology. — The essential lesion of otosclerosis is a 
spongification of the labyrinthine capsule. It is an 
apparent absorption of the osseous elements and the 
deposit of new bone of altered structure. This new spongy 
bone has large Haversian canals, and medullary spaces, 
with abundant multinuclear cells. These foci may be 
more or less localized or may be quite extensive, a large 
part of the labyrinthine capsule being involved; but the 
line between the diseased area and the normal bone is 
quite sharply defined. These areas take the hematoxylin 
and carmine dyes much stronger than the normal parts 
of the bone. When the process develops near the surface 
of the bone, it creates an elevation above the level of the 
surrounding parts; in this way a focus in the niche of the 
oval window may interfere with the motility of the stapes 
or, in the internal auditory meatus, may produce a degen- 
eration of the eighth nerve. A favorite location for the 
process to begin is in the cochlea immediately in front of 
the oval window. In this location not only by thickening 
the wall of the niche of the oval window, but by absorp- 
tion of the annular ligament and the deposit of this new 
spongy bone in this structure as w^ell as in the foot-plate 
of the stapes, an ankylosis of the stapedio-vestibular 
articulation is formed. It may also be noticed that in 
this location if there is a circumscribed affection of the 
organ of Corti adjacent to the diseased process in the 
bone, it would invohe that part of this organ which it has 
been assumed is concerned in analyzing and registering 
the high-pitched notes of the musical scale. This accounts 
for lowering of the upper-tone limit, which is not infre- 
quently seen occurring with stapedial ankylosis in this 
disease. Whether the process begins in the cochlear 
wall adjacent to the oval window or in some other part 
of the labyrinthine capsule, there not infrequently results 
an involvement of the membranous labyrinth which 



158 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

ends in complete atrophy of Corti's organ. This degen- 
eration of the essential parts of the organ of hearing 
is characteristic of one form of the disease. The eighth 
nerve is atrophied and becomes smaller, the spiral ganglion 
is degenerated and there is more or less complete atrophy 
of the organ of Corti. There are thus two types of patho- 
logical process: In the one, the labyrinthine capsule 
alone is involved; in the other, in addition to these 
changes which are essential, there is also involvement of 
the peripheral part of the perceptive mechanism. 

Symptoms. — Deafness is a constant symptom of oto- 
sclerosis. If the process in the temporal bone is located in 
such a place that it does not produce this symptom, 
neither the patient's nor the surgeon's attention is directed 
to it. The impairment of hearing may be of any degree 
of severity. It may develop in an ear i)revi()usly healthy, 
or in one the seat of some non-suppurative process. The 
osteitis metaplastica characteristic of it has been found 
in the temporal bones of patients who sullVrcd during 
life with severe deafness and suppurative disease of 
the middle ear, and this being the case, it follows that it 
may exist in the residual processes which remain after 
middle-ear suppuration has exhausted itself. When 
these diseases exist in the middle ear previous to 
the development of the otosclerotic changes, it may be 
difficult to determine when the latter condition develops, 
as the patient previous to this has deafness from his 
middle-ear disease. The deafness in otosclerosis may 
be moderate for some time, or it may become profound 
or even absolute in a comparatively short time. In this 
latter instance the perceptive mechanism is involved. 
Common histories are as follows: That the patient had 
moderate impairment of hearing for several 3^ears, then 
during from three to six months or so it became very 
profound; or the deafness may become fairly well marked 
and remain so for years ; or gradually progress until severe 
deafness ensues and remains stationary, the process never 
involving the perceptive mechanism. As a rule there 



OTOSCLEROSIS, OSTEITIS METAPLASTICA 159 

seems to be no difference in the symptoms, except the 
degree of the deafness and possibly some vertigo, in the 
patients in whom stapedial ankylosis exists, or those in 
whom there is degeneration of the perceptive mechanism. 
The tests, however, are different and will be alluded to 
under Diagnosis. ]Many of these patients suffer from 
tinnitus. This symptom may be the first to attract 
attention and be much harder to bear than the deafness. 
It may be continuous or be less marked at intervals. In 
nervous patients and those who have poor control of 
themselves it may seriously interfere with the patient's 
peace of mind, while he can still bear his deafness with 
resignation. As the deafness becomes profound, the noises 
may continue or become less marked. In patients with 
marked deafness with stapedial immotility, the paracusis 
Willisii is at times present. They hear better in a noisy 
place (see hyperplastic form of O. M. C. C). A small 
percentage of the patients have vertigo. It is not usually 
severe, but if these patients are asked about this symptom 
they say they have had " dizzy spells." Rarely the vertigo 
is severe. In the patients with profound perceptive 
mechanism involvement, the rule is to find the vestibular 
function affected. Either the caloric and rotation reactions 
are absent or very sluggish. Occasionally, however, a 
patient is seen in whom both of these tests are nearly 
normal or but slightly reduced. When the lesion is 
mainly in the conducting mechanism, these reactions are 
not changed from normal. 

Diagnosis. — The diagnosis of otosclerosis is a subject 
which may not be difficult in some instances, while in 
others it may be all but impossible. To consider first the 
disease when the process is located in the inner tympanic 
wall adjacent to the oval window and produces deafness 
by interfering with the motility of the stapes but does not 
produce degeneration of the eighth nerve, the spiral 
ganglion or organ of Corti. In this type the lesion 
evidently acts as one of the sound-conduction mechanism. 
If the deafness is marked, there will be the presence of 



160 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

Bezold's triad, that is, elevation of the lower-tone limit, 
bone conduction greater than air conduction, and increased 
bone conduction. This, however, may occur in O. M. C. C. 
If there are no indications of disease of the middle ear, 
the tube patent and the drum membrane normal, one 
perhaps is inclined to consider the process one of oto- 
sclerosis. If, in addition, there is lowering of the upper- 
tone limit, the process is probably one of otosclerosis. 
There are two points which would still further strengthen 
this probability. They are the history of several instances 
of marked deafness in the patient's family and the *' peach- 
blossom drum membrane." In this characteristic appear- 
ance, which was made much of formerly, the membrana 
tympani is thinner than normal and very translucent, 
so that the color of the mucous membrane on the internal 
tymi)anic wall over the lesion shows through. This 
mucous membrane is not as pale as normal and therefore 
produces this ])ink appearance. It may not be often seen 
and is in no way necessary for the diagnosis of otosclerosis. 
If a process as above detailed occurs in a patient who has 
a chronic catarrhal otitis media, the diagnosis becomes 
difficult. The tuning-fork reactions may be the same in 
both diseases. Reliance must then be placed on the family 
history of the patient, and also lowering of the upper-tone 
limit. It is claimed by many competent men that the 
labyrinth may be involved secondary to a non-suppurative 
otitis media, and that the only indication of this involve- 
ment may be a slight lowering of the upper-tone limit. 
Be this as it may, if the clinical i)icture of the case is such 
that the question of the probability of the process being 
otosclerotic has arisen in the mind of the aurist, the fact 
that there is lowering of the upper-tone limit is surely 
evidence of a by no means insignificant nature that the 
process is one of otosclerosis. In the second type, where 
the lesion in the bone does not interfere with the motility 
of the stapes, and there is degeneration of the organ of 
Corti, the spiral ganglion or the eighth nerve, the tests are 
characteristic of disease of the perceptive mechanism. If 



OTOSCLEROSIS, OSTEITIS METAPLASTICA 161 

such a process develops in an ear in which the conductive 
mechanism is normal, there will be: No elevation of the 
lower tone limit; B. C.<A. C; B. C. — ; and there 
may or may not be lowering of the upper tone limit. 
These patients have profound impairment of hearing as a 
rule, or even absolute deafness. The evident difficulty 
is to determine that there is no other non-suppurative 
disease of the labyrinth which has produced this condition. 
If this condition occurs in one ear and the opposite one 
is affected with an otosclerotic process that can be recog- 
nized as such, it is safe to infer that the process is of the 
same nature, if no reason to believe otherwise exists. If 
the condition is bilateral, one tries to eliminate other 
diseases which might cause it. The patient's complement- 
fixation reaction is taken to exclude syphilis. He is 
questioned as to severe attacks of vertigo which might 
occur in inflammatory or hemorrhagic conditions of the 
labyrinth; as to injuries; as to family history of deafness; 
as to the length of time during which his impairment of 
hearing was becoming worse, etc. After all of these points 
are carefully considered and every other probability 
excluded, one arrives at the conclusion that the patient 
has otosclerosis affecting the perceptive mechanism. 
Making a diagnosis by exclusion is not a popular way 
with aurists, but it has its advantages nevertheless. 

In the third class the disease affects first the sound- 
conducting mechanism and then follows involvement of 
the perceptive mechanism. If one is fortunate enough, 
in such a process, to have made tests before the perceptive 
mechanism has become affected, the nature of the con- 
dition may be quite plain. When this is not the case, the 
tests may show any ratio in the involvement of the two 
parts of the hearing apparatus, and as no two cases would 
be exactly alike, to go into detail as to what might be 
found would only lead to confusion. It may, however, 
be said that in making the tests in these patients one finds 
the results such that they can only be accounted for by 
assuming that there is a lesion in both the sound-conduct- 
ing and sound-perceiving mechanism. 
11 



162 NONSUPPURATIVE DISEASES OF MIDDLE EAR 

A great deal of dependence is placed, by some aurists, 
on the Gelle test in determining stapedial fixation. They 
believe that if negative it is a strong argument in favor 
of the process being otosclerosis. It has been shown, 
under Tests for Hearing, that this simply shows the 
absence of motility of the ossicular chain, and that if 
negative it in no way separates a stapedial fixation, the 
result of the hyperplastic form of O. ]\I. C. C, for instance, 
from one which occurs in otosclerosis. It is therefore 
not of much diagnostic value, but it should always be 
taken and due consideration given to it. 

Prognosis. — The prognosis is more or less uncertain. 
Some ])aticnts go for years without getting much worse, 
while at any time they may become deafer quite rapidly. 
While recognizing the uncertain nature of the prognosis, 
the aurist should never state the case thus ])hiinly to 
the patient, who may l)e one of those who remain station- 
ary for years, and to point to him the ])ossibiHties of his 
disease would be nothing less than a sin. One has no 
right to take hope from these i)atients, neither should he 
unduly encourage it. The conscientious surgeon will 
readily avoid either extreme. 

Treatment. — If these ])atients have otosclerosis engrafted 
upon some catarrhal ])rocess within the middle ear, 
they should be treated exactly as though the former is not 
present. In not a few patients some amelioration of their 
deafness arises from a proper and systematic treatment 
of the middle-ear disease. If the tympanum is normal, no 
improvement will arise from inflation or any other treat- 
ment directed to the middle ear. It may be granted that 
it is not difficult to determine that the tympanum and 
tube are apparently normal, but what aurist is there who 
has not been mistaken on this point. So if there is doubt, 
as there usually is, the patient should have the benefit of 
it, and be treated in a very gentle manner as for an 
O. M. C. C. These remarks apply to the class of cases in 
which the disease is in the conducting mechanism. When 
the perceptive mechanism is involved to the exclusion 



OTOSCLEROSIS, OSTEITIS METAPLASTICA 163 

of the conductive, any treatment directed to the ear is 
placeboic in nature. 

The general health of these patients demand one's 
consideration. They should be examined by a competent 
internist and anything wrong corrected. This is a very 
important item in the treatment of this disease. 

As for remedies, very little may be expected. Politzer 
believes that the disease may at times be kept in abey- 
ance by the internal administration of potassium iodide 
continued over considerable periods of time, while 
Siebenmann claims the same results from phosphorus 
given for months or even years. The patients with 
perceptive mechanism involvement may be gi^^en the 
iodides and pilocarpine, not with much hope of improve- 
ment, however. 



CHAPTER VI. 
ACUTE INELAMMATION OF THE IVHDDLE EAR. 

Anatomy. — A prominent role is ])laye(l in the acute 
inflammatory processes of the middle ear by the various 
folds of mucous membrane existing in the tympanum. 
These are so disposed that, together with the ossicles 
and their ligaments, the tymi)anum is divided more or 
less comi)letely into two sei)arate ])arts which inflam- 
matory swelling renders still more C()mi)Ictc. The divid- 
ing line between the upi)er ])art (the vault) and the lower 
part (the atriinn), as seen through the meatus, may be 
considered as indicated by the short process of the malleus 
and the anterior and posterior folds. ShrapnelTs mem- 
brane forming part of the outer wall of the vault is the 
only boundary of this cavity which is open to inspection, 
while the membrana tensa afl*ords an indication of the 
processes taking place in the atrium. The vault is con- 
tinuous with the mastoid antrum and is in intimate rela- 
tion with the middle cranial fossa. It will thus be seen 
that a suppurative process in the vault may extend to 
the mastoid cells or meninges, while in the atrium it 
may extend through the oval and roimd windows to the 
labyrinth or in rare instances through the floor of the 
tympanum to the jugular bulb. 

Definition. — Acute otitis media is an inflammation of 
the mucous membrane of the middle ear. As at present 
conceived it is of an infective nature. It varies greatly 
in the severity of the reactionary symptoms and in the 
degree of development and location of the pathological 
process. To the mild type, in which the inflammation is 
confined to the lower part of the tympanum and stops 



OTITIS MEDIA CATARRHALIS ACUTA 165 

short of the formation of pus and usually of rupture of 
the drum membrane, the name Otitis Media Catarrhalis 
Acuta (O. ]\I. C. A.) is given. The severe type in which 
the reactionary symptoms are usually more intense, and 
the process affects not only the atrium but in the majority 
of instances the vault and antrum also, and which, if not 
aborted by treatment, progresses to the formation of pus, 
is called Otitis Media Purulenta Acuta (O. M. P. A.). 
It must be conceded that this division is not all that could 
be desired and various attempts at a better classification 
have been made, but so far without success. To call 
both of these types purulent because they are due to bac- 
terial invasion, no matter what form the reaction may 
take or how mild the inflammation, is evidently unsatis- 
factory. This is, however, done by some authors and 
the term Acute Catarrhal Otitis Media is given to that 
class above described as Tubotympanites. As has been 
shown, this is more or less of a passive congestion, and to 
call it an inflammation is inexact and only leads to con- 
fusion. As there are two types of acute otitis media, 
which may be differentiated clinically and demand dif- 
ferent treatment, it seems best to consider them under 
the heads given above, notwithstanding the fact that the 
processes are very much alike and differ mainly in their 
intensity and the degree of their development. 

OTITIS MEDIA CATARRHALIS ACUTA (O. M. C. A.). 

Acute catarrhal otitis media is an inflammation of the 
tympanic mucous membrane, limited to the atrium, of 
comparatively mild type which does not result in the 
formation of pus. 

Etiology. — The disease is very common in children 
with adenoids and there is no doubt but that these stand 
in a causative relation. When it results from bathing, 
it is due to water entering the middle ear through the 
tube. The habit of diving and after coming up, blowing 
the nose violently, results in forcing some of the water 



166 ACUTE INFLAMMATION OF MIDDLE EAR 

which has found its way into the nasopharynx through 
the tube into the middle ear. The author has noticed 
that bathing in the more congested locations where bac- 
teria are more abundant often results in the production 
of the severer form of otitis media. Other causes are 
taking cold, measles, use of the nasal douche and in general 
the same as those of O. M. P. A. 

Pathology. — The infection probably always gains access 
to the tympanum through the Eustachian tube. There 
is an active congestion and swelling of the mucosa extend- 
ing to the tympanic folds which by their swelling c()mi)lete 
the division of the cavity into two separate com])artments. 
The first factor in the imxluction of an infiammation of 
mild type is this division l)y which the process is limited 
to the atrium. If as the serum exudes and mucus is 
produced, the Eustachian tube is of sufficient patency 
to afford substantial drainage of these products of infiam- 
mation, it constitutes the second factor, while the third 
is the better resistance of the ])atient, the fourth being 
the fact that the infection is of milder nature. As the 
inflammation subsides, the serum and mucus drain 
through the Eustachian tube, or are absorbed or are being 
retained, the process becomes chronic. As the vault 
does not take part in the process there is no extension to 
the antrum, the mastoid cells or the meninges. 

Symptoms. — The most common symptom is pain. It 
may be regarded as practically constant. It varies greatly 
in severity but is usually sufficient to keep the patient 
awake at night. While the patient also has more or less 
deafness, perhaps tinnitus, it is not for these symptoms 
that he seeks advice. It is well, however, to make a 
record of impairment of hearing which will be found to 
show the tests characteristic of involvement of the sound- 
conducting mechanism. In children fever may be present 
not usually over 103° F., although in infants it may be 
higher and the attack ushered in by convulsions. Fever 
is not common in adults although a rise of a degree or 
p may be met with. 



OTITIS MEDIA CATARRHALIS ACUTA 167 

Signs. — The drum membrane presents characteristic 
changes. The hister is diminished but very rarely, if 
ever, absent. The color is changed, appearing redder 
than normal, the degree varying considerably. The 
membrane may be depressed in the early stages but usually 
when the patient comes under observation it is normal 
in position or less depressed than normal. In one type 
only (to be mentioned later) is its integrity impaired. 
The change in the structure is not marked, although some 
thickening and loss of the natural translucency may be 
present. All of the changes are limited to the membrana 
tensa. Beyond a physiological reddening of the membrana 
flaccida no changes are present in this membrane. If 
the ear is inflated, there will be found to be fluid in the 
tympanum. 

Diagnosis. — That there is an acute inflammatory pro- 
cess in the middle ear is usually readily made out by the 
pain (and fever in children) with the change in color and 
luster of the membrana tympani. In differentiating the 
process from an 0. ]M. P. A. the question resolves itself 
into whether or not the patient is suffering from a process 
capable of resolution. If so it is called O. ]M. C. A. and 
treated expectantly. In arriving at a conclusion the fol- 
lowing points are taken into consideration. (1) Pain: 
its severity and duration. It is less severe in O. M. C. A. 
If the patient comes under observation early in the attack, 
it will still be present and at its height; if later, say on 
the second or third day, it should be less and diminishing 
in intensity. (2) Fever: this should be less in O. ]\I. C. A. 
It is, however, of little value in diff'erential diagnosis. 
(3) Changes in the membrana tympani. Always limited 
to the membrana tensa in O. M. C. A. and consisting as 
a rule of change in color and luster with slight alteration 
in structure. Bulging or loss of integrity, except as men- 
tioned below, are not present in O. M. C. A. Changes in 
O. M. P. A. apt to be in Shrapnell's membrane, are 
discussed under that disease. (4) Finally the occurrence 
of mastoid involvement excludes O. ]\I. C. A. If upon 



168 ACUTE INFLAMMATION OF MIDDLE EAR 

examining a patient one feels that he is not justified in 
postponing incision of the drum membrane, he cannot 
make a diagnosis of O. M. C. A. The following are three 
types of history in which the author feels justified in mak- 
ing this diagnosis: (1) A child suffers with pain and 
fever, usually not over 103° F. This continues a few hours 
when there is relief from pain and the temperature begins 
to subside. Soon a seromucous discharge appears, or 
the mother notices a stain upon the pillow. When the 
ear is examined twelve to twenty hours later it is found 
that the drum membrane is healed and in process of 
resolution or the discharge may continue for a day or 
so, never becoming purulent. (2) A patient comes com- 
plaining of fulness in the head, tinnitus or deafness, and 
states that from twenty-four to forty-eight hours pre- 
viously he had severe pain lasting (usually) less than 
twenty-four hours, when it gradually subsided. The 
drum membrane is red, the luster is somewhat diminished, 
bulging is not present, although the natural dejH-ession 
is somewhat lessened and the structure is slightly, if at 
all, altered. All of these changes will be less the longer 
the time which has elapsed since the attack of ])ain. If 
inflated, fluid is found in the tympanum. This is evi- 
dently a resolving O. ]\I. C. A. (3) A patient with the 
same kind of a process may present himself early, that 
is, during the height of the pain. In making a decision 
one takes into consideration that the pain has not lasted 
long, is perhaps not as severe as one would expect in an 
0. M. P. A. The drum membrane while somewhat red, 
possesses some luster, is not bulging, the structure not 
seriously altered and Shrapnell's is normal or at most 
shows only a physiological redness. One feels that the 
process is capable of resolution without incision or rupture 
of the drum membrane, calls it O. jNI. C. A., and treats 
it expectantly. If in twenty-four hours the pain is less 
severe or absent and the fundus changes no worse or are 
beginning to improve, the correctness of one's judgment 
has been demonstrated. If, on the other hand, in twenty- 



OTITIS MEDIA CATARRHALIS ACUTA 169 

four hours the pain has not diminished or has increased 
and the fvuidus changes have become more marked, one 
discovers that he underestimated the process and must 
revise his diagnosis, call it O. M. P. A. and proceed 
to treat it as such. In comparing the changes in the 
fundus, reliance must be placed, not so much on the 
difference in the color, as in the luster, structure and 
position. With more diminution in luster, increase in 
the thickness of the membrana tensa and bulging and 
especially if Shrapnell's membrane shows any sign of 
involvement, the process declares itself to be a severe 
one, incapable of resolution without incision of the drum 
membrane and therefore an O. M. P. A. 

Prognosis. — The prognosis of O. M. G. A. is good. The 
process in the majority of patients ends in cure without 
much impairment of hearing. Nevertheless, the attack 
may result in adhesions or thickening of the mucous 
membrane which produces impaired hearing. This is 
much more probable to result when repeated attacks 
occur. 

Treatment. — ^Many attacks may be prevented. The 
adenoids should be removed. Children with these growths 
in the nasopharynx are very susceptible to attacks of 
this form of acute middle-ear inflammation. The mother 
states that the child is subject to ''ear aches" which have 
probably been attacks of O. M. C. A., and have frequently 
resulted in more or less impairment of hearing when 
the patient comes under observation. Removal of the 
adenoids usually results in the relief from future attacks. 
The tonsils if enlarged should also be removed, although 
their influence in producing this condition is much less. 
Bathers should be cautioned against diving and then 
forcibly blowing the nose, and congested pools or parts 
of the shore should be avoided. The nasal douche should 
be discarded and an atomizer substituted if it is necessary 
to cleanse the nose. 

In treating the attacks no ear drops are to be used. 
They do no good. A patient who gets well after the 



170 ACUTE INFLAMMATION OF MIDDLE EAR 

instillation of any of the various compounds devised and 
prescribed either by the laity or others has recovered in 
spite of, but not on account of, them. While being of 
no use they mask the appearance of the fundus changes 
so that one is often in doubt as to the treatment to pur- 
sue. A very gentle inflation sometimes helps these 
patients. The nose and tubal orifice is anesthetized with 
a solution of cocaine before inflation. One or two quite 
gentle compressions of the bulb should be made, just 
sufficient to force air into the tympanum. No attempt 
to drive the secretion from the tympanum through the 
tube, such as is made in tubotympanic congestion, is 
justifiable. After inflation a solution of silver nitrate, 
4 per cent., is applied to the mouth of the tube. If this 
treatment results in impr()\'ement, it may be repeated 
in twenty-four to forty-eight hours. Or if one feels timid 
about inflating such a ])atieut, the silver nitrate solution 
may be a])])lied, after anesthetizing the tubal orifice and 
the inflation dispensed with. Ileat api)lied to the side 
of the head and ear often seems to relieve the pain and 
make the patient more comfortable. Anodynes, such as 
any of the preparations of ()j)ium, should not be adminis- 
tered, as they mask the pain upon which a decision as 
to the necessity of a myringotomy may eventually rest. 
After the acute symptoms have subsided the patient 
should be inflated and the silver solution api)lied to the 
tube every two to three days until the tympanum is dry 
and the hearing becomes as near normal as can be expected. 

OTITIS MEDIA PURULENTA ACUTA (O. M. P. A.). 

Acute purulent otitis media is the severer form of 
inflammation of the mucous membrane of the tympanum, 
which if not aborted by myringotomy (as it only occasion- 
ally can be) results in the production of pus. 

istiology. — The disease may follow a cold in the head, 
especially if the accessory sinuses are involved. Chronic 
sinusitis is also frequently a cause. The purulent secre- 



OTITIS MEDIA PVRULENTA ACUTA 171 

tion from these cavities finds its way into the nasopharynx, 
then by blowing the nose, it is forced into the middle 
ear throngh the tube. If the epithelium covering the 
tubal mucosa is absent through inflammation or any 
other cause, the protection against bacterial invasion 
afforded by the cilia is lost. This cause, doubtless, operates 
in many of the nasopharyngeal infections to make the 
tympanum more vulnerable. Adenoids furnish a favor- 
able field for the lodgement and development of bacteria 
and also interfere with the proper aeration of the middle- 
ear spaces and are a frequent cause of the disease. The 
use of sprays or nasal douches when adenoids are present 
often leads to forcing infection through the tube. Enlarged 
tonsils may be a factor in the causation but not as fre- 
quently as adenoids. Atrophic rhinitis, by furnishing 
a constant supply of germs in the nose and nasopharynx 
near the tubal orifice, is an ever-present menace. These 
patients are frequently the subjects of middle-ear inflam- 
mation. Indeed it seems strange that so many of them 
escape. When they seek advice and a nasal douche is 
prescribed to remove the crusts, the conditions favoring 
middle-ear infection become almost ideal. Xasal and 
nasopharyngeal operations are not infrequently respon- 
sible for an O. M. P. A. If it becomes necessary to use 
a postnasal tampon, the danger is increased. For this 
reason this device should be avoided in epistaxis if it is 
at all possible to control the hemorrhage otherwise. 
Tuberculosis frequently causes the disease (see Tuber- 
culosis of the Ear). Scarlatina, diphtheria and measles 
have lesions of the nose or nasopharynx which may extend 
to the ear and in fact frequently do so. The disease occurs 
in pneumonia, typhoid fever, influenza, variola, in fact 
any of the infectious diseases. Injuries of the membrana 
tympani, especially with infected instruments or foreign 
bodies, are at times responsible for O. ]M. P. A. 

Pathology. — The atrium may be involved alone but 
this is the exception. The vault may be involved alone, 
the infection passing through the atrium and gaining 



172 ACUTE INFLAMMATION OF MIDDLE EAR 

access to the vault, which becoming walled off by the 
swelling of the mucous membrane folds, undergoes a 
suppurative inflammation, while the process in the 
atrium, never being severer than an O. M. C. A., sub- 
sides, leaving the disease localized in the vault. Or both 
divisions of the tympanum may be involved at the same 
time, which is the usual condition. Postmortem examina- 
tions have shown the tympanic mucous membrane to be 
swollen and infiltrated with a serous exudation and pre- 
senting ecchymotic areas, the epithelium, cloudy, swollen 
and cast off in places. The infection usually reaches the 
tympanum through the tube, occasionally through a 
solution in continuity of the drum membrane. That it 
is possible for the infection to be carried to the tym- 
panum through the blood stream or lymph channels 
cannot be denied, but the instances in which it does so 
are rare. Many different bacteria are capable of produc- 
ing the disease. The more common reports from the 
laboratory on the results of the examinations of smears 
or cultures of the aural pus are: long- or short-chained 
streptococci, pneumococci. Streptococcus capsulatus, 
staphylococci or mixed infection. Occasionally some of 
the rarer forms are found. 

Symptoms. — Pain is a predominant symptom of this 
disease. It may be located in the ear or radiate over 
the side of the head. While there may be remissions, it 
is usually more or less constant until the drum membrane 
has either been incised or ruptures when it usually sub- 
sides. It is apt to be worse at night and in the recumbent 
posture. The patient usually describes it as ^'boring 
or throbbing" in character. Very rarely the patient may 
state that at no time has he had any pain. This frequently 
occurs in tubercular process but outside of these is seen 
occasionally. As the pain is caused by tension either 
from swelling of the mucous membrane or the accumula- 
tion of secretion, it seems strange that sufficient tension 
to produce rupture of a previously normal drum mem- 
brane can exist without pain, but it does so, although 



OTITIS MEDIA PURULENTA ACUTA 173 

very rarely. Fever frequently occurs in children. In 
infants the temperature may reach 105° F., and the 
attack begin with convulsions. In older children the 
temperature seldom rises above 103° F. or 104° F. from 
the otitis media alone. Adults may have some fever but 
it is not uncommon for the disease to be afebrile. With 
a temperature of 103° or even less in an adult or adoles- 
cent one suspects the presence of some complication. 
Tinnitus may be an early symptom before the disease 
is sufficiently developed to produce pain and it is fre- 
quently complained of as the process is subsiding. During 
the height of the process it does not usually attract the 
patient's attention on account of the pain and discharge. 
The same is also true of deafness which is invariably 
present to a greater or less degree. x4s the reactionary^ 
symptoms subside the impairment of hearing is very 
frequently complained of. It arises from lack of motility 
of the drum head, from thickening of the mucous mem- 
brane which interferes with the vibrations of this struc- 
ture or those in the oval and round window^s, or from fluid 
accumulating in the region of the fenestrse. Except the 
lab}Tinth is involved the deafness shows the tests charac- 
teristic of disease of the conducting mechanism. Vertigo 
if present should always lead one to suspect labyrinthine 
disease, although it may occasionally be due to pressure 
upon the fenestrse or to vascular disturbance arising 
from the severe inflammation in proximity to these win- 
dows. In about 10 per cent, of the patients there develops 
loss of one or more of the sensations of taste on the anterior 
two-thirds of the tongue on the involved side. Either 
the ability to perceive all fom* of the primary tastes, 
acid, bitter, sweet and salty, is lost, in which event the 
corda tympani is totally involved or some of them may 
be perceived when it may be presumed that the corda is 
but partially involved. 

Discharge is a constant symptom. If it follows an early 
incision of the drum membrane, it is usually serous or 
serosanguinolent for a day or so, but if it persists it 



174 ACUTE INFLAMMATION OF MIDDLE EAR 

becomes purulent. If spontaneous rupture of the mem- 
brane occurs early, the discharge may have the same 
appearance for a day or so, soon to become purulent. 
When the rupture takes place later or the incision has not 
been made early, pus usually is the major content of the 
discharge after the blood is washed away. Outside of 
these considerations the amount and character of the 
discharge vary greatly. It usually continues free until 
the height of the process is passed, when it is apt to 
become less purulent and more mucoid in character and 
gradually cease. At times a free myringotomy seems 
to abort the process and the discharge never becomes 
frankly purulent but is serosanguinolcnt and continues 
a few days only, containing, however, pus cells and 
bacteria in abundance. In other patients the discharge 
becomes very free and leads one to suspect the ])resence 
of a mastoid abscess; being much more in amount than 
could come from the middle ear. Between these two 
extremes any variation may occur. The otorrhea instead 
of diminishing to a cure in from one to six weeks may 
persist, passing into a chronic condition. This is the 
usual occurrence in tu})ercular patients and is frequent 
in children with adenoids and when the disease follows 
scarlatina and diphtheria. In infants with marked 
patency of the Eustachian tube sufficient relief to the 
tension in the middle ear may be afforded by discharge 
through this passage, so that the membrana tympani 
does not rupture. This process if unrecognized may con- 
tinue for some time, the child having a varying amount 
of pain and fever. 

Signs. — The color of the membrana tympani is changed. 
In the beginning of the process the membrane is injected 
along the manubrium and the tympanic ring, soon the 
change in color extends to the membrana tensa which 
often becomes a bright red. As the process goes on the 
color usually diminishes to a dull or even livid redness. 
There may be ecchymotic spots or hemorrhagic bullae, 
especially in the influenzal otitis media. If there are 



OTITIS MEDIA PURULENTA ACUTA 175 

interstitial abscesses or the merabrane becomes thin 
from the pressure of the pus and is about to break down, 
yellowish areas may at times be seen, which indicate 
where rupture is about to take place. The luster of the 
drum membrane is due to the peculiar character of its 
epithelial covering, and for the luster to be normal this 
layer must be intact. As this is affected by the inflam- 
mation, the luster diminishes to a varying extent, depend- 
ing upon whether the epithelium is merely changed by 
the exudation or exfoliates en masse. To a certain extent 
color and luster are correlative. The brighter the color, 
the less the loss of luster, as in the early stages; while 
in a type which is sometimes seen a little later in the 
disease the loss of luster is absolute, the membrane 
appearing not unlike wet blotting paper. This type of 
membrane is due to death, en masses of the epithelial 
covering and shows no redness whatever, although if 
the macerated epidermis is removed, as it usually can be, 
the membrane appears red. Care must be taken not 
to mistake for luster the light reflex from secretion which 
may cover the drum membrane. Sometimes these reflexes 
are pulsating in appearance due to the effect of the 
cardiac contractions on the intratympanic blood supply. 
In exceptional instances the membrana tensa may be 
nearly normal in color and luster. In these the process 
involves the vault alone, the disease in the atrium having 
resolved and the changes are in Shrapnell's membrane. 
This structure frequently appears altered in color, show- 
ing varying degrees of redness, but the color changes in 
Shrapnell's are as a rule not of as much importance as 
changes in position. Theoretical^, the drum membrane 
should be depressed from tubal occlusion at the very 
beginning of the attack. Patients are practically never 
seen at this stage. When they come under observation, 
the position of the membrane is either less depressed 
than normal or bulging. This outward movement of 
the drum head is due either to the swelling of the mucous 
membrane internal to it, or to the accumulation of 



176 ACUTE INFLAMMATION OF MIDDLE EAR 

secretions. It may involve the whole membrane, Shrap- 
nell's included, or be limited to the membrana tensa or 
some part thereof. When the whole membrane bulges, 
the manubrium may lie in a gutter where it holds the 
membrane relatively depressed. If the manubrium can 
be made out, it often seems lengthened, the converse 
of the foreshortening with depressed membranes. If the 
bulging is localized, it may be in the posterosuperior 
quadrant and extend into ShrapnelVs membrane. These 
bulging areas usually collapse after ru])ture, but before 
this occurs a conical process may be produced which 
remains after a small perforation has occurred. These 
conical perforations are often associated with mastoid 
abscess. When occurring in Shrapnell's membrane, they 
may attain considerable length and in extreme instances 
even present at the external end of the meatus, very 
closely resembling an aural polyj). 

When the patient comes under observation rui)ture 
may not have taken place, the membrane being intact, 
or there may be a perforation. Usually there is but one. 
In tubercular process there may be more than one. Spon- 
taneous perforations are i)erhai)s more frequently found 
in the anterior half of the drum head. If fhfficulty is 
experienced in locating the perforation, the expedient 
suggested under ^'Examination of the Patient" should be 
tried. Inflation may thus show the location of the open- 
ing and give valuable information as to its size and the 
sufficiency of drainage. As the process resolves the per- 
foration usually heals with cicatricial tissue before the 
changes in the intratympanic membrane have completely 
subsided. At times a discharge occurs without a per- 
foration in the drum head, the pus dissecting its way out 
through the Rivinian segment beneath the periosteum, 
and producing a rupture on the canal wall. In infants 
in exceptional instances the drum head may remain intact, 
the pus escaping through the Eustachian tube. The 
structure of the membrane is altered by infiltration with 
inflammatory products and swelling of its mucous and 



OTITIS MEDIA PURULENTA ACUTA 177 

fibrous layers. In interpreting this sign, one notices that 
the membrane, independent of its loss of luster, seems 
less translucent than normal. When the thickening is 
extreme, it may be impossible to make out the manubrium, 
the short process is obscured and the drum head seems 
opaque. Change in structure is regularly present in 
O. ]M. P. A., and in membranes without marked diminu- 
tion in luster or chajige in color it becomes a valuable , 
sign in diagnosis. The tough, thickened membranes which 
fail to rupture spontaneously are among the most dan- 
gerous, in view of the complications which they produce 
by delaying the establishment of drainage. 

Diagnosis. — ^That the patient has an acute middle-ear 
inflammation is readily determined by the symptoms 
and history together with the otoscopic examination. 
Whether the process is an O. M. C. A. and may be treated 
expectantly, or is an O. M. P. A., and demands myrin- 
gotomy, has to a certain extent been discussed under 
the former disease. It may be added, however, that the 
diagnosis of O. -NI. P. A., and therefore the indication for 
myringotomy, rests on the following points : severe pain, 
especially if associated with mastoid tenderness; fever 
attributable to the aural process; bulging of the drum 
membrane, especially if in Shrapnell's or conical in form; 
a yellow area in the membrane indicating that pus is 
about to break through; marked diminution of luster, 
especially if the membrane resembles wet blotting paper; 
marked change in structure. Any one of the drum mem- 
brane changes given above, if associated w^ith pain or 
fever, indicate the necessity of myringotomy. If the 
pain is mild or even absent, the fundus changes alone 
enable one to decide. After the membrane ruptures and 
the discharge appears, the diagnosis is established by 
this symptom alone. If an otitis externa has produced 
occlusion of the meatus or the same result has been caused 
by strictures or exostoses, so that a view of the fundus 
cannot be obtained, the diagnosis before the appearance 
of the discharge may be very difficult. One would then 
12 



178 ACUTE INFLAMMATION OF MIDDLE EAR 

rely on the intensity of the pain, the amount of fever, 
and perhaps also the occurrence of mastoid tenderness. 
After the discharge appeared its quantity, nature, and 
bacterial content would enable one to decide. 

Prognosis. — The result of an acute purulent otitis media 
is always more or less doubtful. A great many patients 
recover and have very good or even slightly diminished 
hearing. Others recover with more or less deafness or 
tinnitus. These symptoms are due more to the resulting 
intratympanic changes than to any effect i)ro(luced upon 
the drum head. Adhesions between the ossicular chain 
and tympanic wall, as well as thickening of the mucous 
membrane in the niches of tlic labyrinthine fcnestne 
may remain and ])r()f()un(lly att'cct the hearing. One 
sees at times ears which are totally deaf as the result of 
a supjnirative process. r])<)n testing them loss of hearing 
is found to be due to a lesion of the perceptive mech- 
anism, doubtless due to a labyrinthitis which occurred 
at the time of the attack. The perforations in the mem- 
brane usually heal with more or less cicatricial tissue, 
according to the amount of sloughing in the original 
process. Some cases become chronic no matter how care- 
fully treated. Mastoiditis of mild degree occurs in every 
patient who has involvement of the vault, and this is 
in the majority. It may resolve or demand oi)eration. 
Sinus thrombosis, meningitis, brain abscess or labyrinth- 
itis are other comi)lications which are far from rare. No 
one is able to tell in achance the ])atients who will develop 
these complications. - So the prognosis, while guarded, 
should be encouraging. Bacteriological examination of 
the aural pus may throw some light on the probable ter- 
mination, although too much reliance should not be 
placed upon it. The Streptococcus capsulatus and to a 
lesser degree the pneumococcus are the cause of processes 
which show a tendency to invade the mastoid and pro- 
duce mastoid abscess and other complications (see Mas- 
toiditis). These infections influence the prognosis in 
that the progress of the disease is more insidious and less 



OTITIS MEDIA PURULENTA ACUTA 179 

painful and therefore its extent may not be realized. 
The prognosis is not so good in diabetics and others with 
low resistance. The processes caused by scarlatina and 
diphtheria are more apt to become chronic than other 
types, except the tubercular, which is almost certain to do so. 
Treatment. — When a patient suffering from this disease 
presents before spontaneous rupture of the drum mem- 
brane has taken place, myringotomy is indicated. As 
long as it is safe to hope for resolution, one considers 
the process an O. M. C. A., and treats it accordingly. 
But once it is seen that this is not probable to occur, 
the diagnosis is changed to O. M. P. A. and the mem- 
brane is incised. In coming to this decision the benefit 
of any doubt should be cast upon the side of a prompt 
incision of the membrane. The process is one in w^hich 
the complications are serious and the best that can be 
done to avoid them is to perform an early and free myrin- 
gotomy. Then the resulting scar is less if this is done 
early before necrosis of an area in the drum head results, 
or spontaneous rupture occurs. iVn incision heals with 
a linear scar, while if rupture occurs a greater or less area 
filled in with cicatricial membrane may be expected. 
Incision is also the best means to adopt for the relief of 
pain. It is a bad plan to give these patients anodynes, 
as the pain is an important indication as to the progress 
of the process. They certainly should not be given before 
incision and as this operation usually relieves the pain, 
unless there are complications, it is unwise at any time 
to mask this symptom which may afford so much infor- 
mation. In children the temperature may not fall for a 
day or two after an incision has been made. If one feels 
certain that the atrium alone is involved, the incision may 
be limited to the membrana tensa, but if the vault also 
is taking part in the process it should extend through 
the posterior fold into Shrapnell's membrane. When 
the patient is seen after spontaneous rupture of the mem- 
brana tympani, it remains to determine whether or not 
sufficient drainage has been estabHshed. If the pain is 



180 ACUTE INFLAMMATION OF MIDDLE EAR 

relieved and fever is absent, especially if the perforation 
is of fair size, one is justified in omitting to perform a 
myringotomy. On the other hand, if pain or fever are 
present, especially if the perforation is a small one, the 
drainage is presumably insufficient and an incision 
should be made. Having provided for drainage, the ear 
is syringed every two to four hours, according to the 
amount of discharge. A solution of bichloride, 1 to 5000, 
or boracic acid, one dram to the ])int, may be used. These 
irrigations should be as warm as can be borne with com- 
fort. Eight ounces of fluid if properly used will be suffi- 




t 



Fig. 48. — Soft-rul)})er bulb sj^riiiKc. 

cient to cleanse the ear. Just sufficient force to remove 
the secretions should be used. A soft-rubber bulb is a 
very safe syringe for these patients (Fig. 4S). The ear 
should be drawn upward and backward, or if the patient 
is an infant or young child downward and backward and 
the tip of the syringe placed behind the tragus, but not 
allowed to enter the canal, and the current directed in 
the line of the axis of the meatus. After syringing the 
ear the meatus is dried. The wearing of a wad of cotton 
in the ear, while it may seem necessary in exceptional 
instances, is not to be advocated as a routine. The 
question of whether or not to perform a second myringot- 



OTITIS MEDIA PURULENTA ACUTA 181 

omy in a given patient may arise. This will probably 
occur if relief from the symptoms has not followed the 
first one, or if after the symptoms have become better, 
they recur coincident with the closure or diminution in 
size of the perforation. Before determining to make a 
second incision of the drum membrane, if it is known that 
the first one was properly made, it is well to investigate 
the condition of the mastoid as it will usually be found 
that a mastoid operation is needed and not a myringot- 
omy. Some surgeons go so far as to say that a second 
incision should never be made, but a mastoid operation 
instead. If a free incision does not relieve the symptoms, 
the inference is justifiable that the obstruction to drainage 
is not in the membrana tympani, but is more deeply 
seated and that a second myringotomy would be useless. 
If the symptoms (pain, fever or mastoid tenderness) are 
relieved but recur with closure or contraction of the 
perforation, and the process is still in the first week dating 
from the inception of the pain, a second myringotomy is 
justifiable. The author has in mind a patient upon whom 
he performed the second incision on both sides, under 
these circumstances,, and although the infection was the 
Streptococcus capsulatus, the patient made a good 
recovery without complications and had remained per- 
fectly well when seen three years later. Another question 
which may arise is. When should the adenoids be removed ? 
Some surgeons of great experience in treating the aural 
diseases of children, remove the adenoids at the same 
time that the myringotomy is done, claiming thereby to 
lessen the duration of the suppurative process and to 
minimize the danger of complications. This practice 
has, however, not become general. It is perhaps the rule, 
that if the process is not resolving as shown (mainly) by 
the lessening of the discharge in the second or third week, 
to remove the adenoids, unless it is probable that the 
continuance of the discharge is due to mastoiditis. How- 
ever, each case must l)e decided l)y itself, Init in no instance 
should the adenoids be allowed to remain until the dis- 



182 ACUTE INFLAMMATION OF MIDDLE EAR 

charge becomes chronic. The general health and nutrition 
of the patient recovering from an acute suppurative 
process of the middle ear should also receive attention, 
and appropriate measures adopted. 

After the inflammation has run its course and the drum 
membrane is healed, an attempt is made to limit the 
amount of resulting deafness. Inflations, by breaking 
up adhesions and producing a pneumomassage of the 
mucous membrane, may be of value. They should not 
be begun until the drum membrane is in process of resolu- 
tion, and the luster and structure are returning to nor- 
mal. Inflations must be very gentle at first until it is 
ascertained that they do not ])r()(hice painful reaction. 
They are to be followed by the appHcation of nitrate of 
silver or argyrol to the mouth of the tube in the same 
manner as in tubotympanites, and contiiuied at intervals 
of two or three days until the ear becomes dry, the tube 
remains patent and as much improvement of hearing 
gained as can be expected. It should, however, be ascer- 
tained that the impairment of hearing is due to lesion 
of the sound-conducting mechanism before persevering 
in this treatment. 

MYRINGOTOMY. 

Instruments. — The proper instrument for incising the 
drum membrane is a small scalpel (Fig. 49). The cutting 
edge may be convex, straight or slightly concave, accord- 
to the preference of the operator. Lance-pointed knives 



i l J VM'II I . r 1 1 MI^AWM J 



Fig. 49. — Myringotomy knife. 

should be avoided as the intention is to incise not to 
''pierce" the membrane. 

Asepsis. — ^The operation should be done in a thoroughly 
aseptic manner. If the normal membrane is incised in 



MYRIXGOTOMY 183 

this way, no reaction will take place, but the margins of 
the incision will heal in a few days, at the longest. At 
times the operation may be done when infection is absent 
from the middle ear, and in any event, whether this is the 
case or not, infection should not be introduced by the 
surgeon. The ear is to be syringed with a solution of 
bichloride of mercury, 1 to 2000, dried, and the meatus 
wiped with bichloride and alcohol. The auricle and sur- 
rounding parts washed with soap and water, dried, then 
wiped with gauze saturated with alcohol and bichloride. 
The hands of the surgeon should be thoroughly cleansed 
and all instruments sterilized. 

Anesthesia. — General anesthesia is preferred. Nitrous 
oxide gas, being rapidly administered and recovered from 
without unpleasant effects, is the anesthetic of election. 
^Yhen it is not available and the patient is a child, a few 
whiffs of chloroform, just sufficient to produce primary 
anesthesia, is all that can be desired. Local anesthesia, 
although used by many, has not become popular. Advo- 
cates of this method use a mixture of menthol, carbolic 
acid and cocaine, equal parts. They should be rubbed 
together in a mortar without the addition of even a drop 
of alcohol or other fluid. The drum membrane is painted 
with this mixture in the line in which it is proposed to 
make the incision. As the parts become blanched, anes- 
thesia is usually as profound as it will become, and the 
incision is made. The objections to this method are that 
it does not always cause a painless operation, and more 
or less reaction of the membrane and walls of the canal 
takes place. This inflammation and swelhng interferes 
with the proper appreciation of the subsequent progress 
of the disease. While anesthesia is ahvays desirable, it 
is possible to perform the operation without it. 

Incision without Anesthesia. — If this is attempted, the 
head of the })atient must be firmly held by an assistant 
so that the patient will not move away from the oj^era- 
tor as the knife touches the drum membrane. The 
patient's hands should also be held so that he does not 



184 ACUTE INFLAMMATION OF MIDDLE EAR 

grasp the surgeon's arm as the incision is being made. 
The knife is held by the index finger and thumb of the 
right hand in such a manner that when introduced into 
the canal and the point is near the drum head, the other 
three fingers rest upon the mastoid or cheek, according 
to whether the left or right membrane is about to be 
incised (Fig. 50). The thumb and finger thus holding 
the knife are capable of extension, while the other three 
fingers maintain their rest upon the patient's mastoid or 
cheek, and thus the whole hand moves with the patient's 




\s 



Fig. 50. — Position of the hand and fingers wliile holding the knife 
in incising the drum membrane. The thumb and index finger extend 
and complete the incision. 



head while the incision is being made by the excursion 
of the thumb and index finger. Thus one is able to incise 
the membrane, notwithstanding a moderate moving 
away of the head. This method of holding the knife has 
another advantage in that the incision is made by move- 
ment of the thumb and finger, which is much more deli- 
cate than it would be if executed with the w^hole arm or 
hand. If, therefore, the blade of the knife encounters 
the long process of the incus, it is more readily turned 
aside. It will also be found verv convenient even if the 



MYIRIKGOTOMY 185 

patient is anesthetized, although in this case any method 
of holding the knife that appeals to the operator is per= 
missible as the incision is performed in a more deliberate 
manner. 

Location of Incision. — The incision is usually made in 
the posterior part of the drum membrane. Circumstances 
are very rare which render it desirable or advisable to 
make the incision anterior to the manubrium. The pos- 
terior half is more accessible and if it becomes necessary 
to extend the incision into ShrapnelFs membrane, as is 
frequently the case, it can readily be done from the pos- 
terior position, while if the incision is made anterior to 
the manubrium, it would be done with difficulty. More- 
over, the part of the tympanic cavity which it is desired 
to drain is the posterior which is adjacent to the posterior 
part of the vault communicating with the antrum. 

Anatomical. — It is necessary to bear in mind the anatom- 
ical structures on the internal tympanic wall; the niche 
of the round window, the oval window containing the 
stapes articulated with the long process of the incus, and 
between these two fenestrse and anterior to them, the 
promontory which approaches very near to the tympanic 
membrane when the latter occupies its normal position. 
^Yhen it is necessary to incise the drum membrane, it 
has frequently, on account of the bulging, receded from 
the promontory so that the depth of the cavity has 
increased. 

Making the Incision. — The incision should always be 
made in an upward direction, not only because it is more 
convenient, but because it is safer also. The jugular bulb 
is in relation with the floor of the tympanic cavity. At 
times the bony structure which covers it in this location 
is very thin or absent, so that the knife, if directed down- 
ward, may wound the bulb. In rare instances the dome 
of the jugular bulb rises into the tympanic cavity, when 
it would almost certainly be wounded if the incision was 
made downward and might be, no matter how the incision 
was made. Fortunatelv this anomalv is rare and the 



186 ACUTE INFLAMMATION OF MIDDLE EAR 

possibility of its occurrence should not make the surgeon 
timid in performing this operation. The knife is entered 
as low as possible and the incision made upward, parallel 
with the tympanic ring (Fig. 51). If it is desired merely 
to open the atrium, the incision stops just short of the 
posterior fold. This may be the case in mild processes 
limited to the atrium; usually, however, it is best to 
continue the incision through Shrapnell's membrane until 
the knife impinges upon the bone in the Rivinian segment. 
It is then drawn out ak)ng the posterosuperior wall for 
about one-fourth of an inch, cutting the soft parts down 
to the bone. This part of the incision lies directly over 
the antrum and is supposed to (k*i)lete the tissues and in 




Fig. 51. — Incision of the menibrana tympani. A-B, incision totally 
in the menibrana tensa. A'-B, incision extended through Shrapnell's 
membrane. 

some way produce a beneficial effect on an inflainmatory 
process within the antrum. When the point of the knife 
has penetrated the membrana tympani, it usually comes 
in contact with the promontory. If it does not, no attempt 
should be made to extend it until bone is encountered. 
The point of the knife may be directed toward the oval 
window or the niche of the round window, and if the 
surgeon believes that he must pass the knife until its 
point encounters bone, the labyrinth may be penetrated 
with disastrous consequences. As the blade of the knife 
moves upward, the long process of the incus may be 
encountered. The instrument should be held with a light 
grasp and allowed to deviate to avoid injury to this 
structure. 



MYRINGOTOMY 187 

Sufficiency of the Incision. — After the incision is made, 
as the operation is so soon completed, the beginner fre- 
quently feels that not enough has been done. This 
desire to go in again and ''complete the work'' should be 
restricted, as nothing of value can be accomplished in a 
field so obscured by hemorrhage. For the same reason, 
it is impossible by inspection to ascertain whether or not 
the incision is sufficient. Inflation might decide this 
question, but it is usually a bad practice to inflate an ear 
which has just been incised. It will be much easier to 
determine this on the following day both by inspection 
of the drum membrane and the amelioration of the 
symptoms, which will usually take place if the operation 
is properly performed. The discharge may also furnish 
some information on the subject. 

Accidents. — The amount of bleeding after the operation 
varies greatly. At times blood will only appear exter- 
nally at some interval after the incision has been made, 
while, again, the external auditory canal may become 
at once filled with blood. If the jugular bulb was wounded, 
this would occur before the operation was completed. 
For the ordinary hemorrhage nothing should be done, as 
the depletion caused by it is in every way desirable. If, 
however, it is so free or persistent that injury to the 
bulb may reasonably be inferred, it must be checked. 
This can u'sually be done by packing the canal firmly 
with gauze and an outside pad applied in such a manner 
that pressure is exerted upon the gauze within the meatus, 
the whole to be held in place by a snug bandage. The 
patient is put to bed and observed and treated in the 
manner outlined under Sinus Thrombosis. There is 
naturally danger of this condition developing, but it may 
not occur. 

In the operation as described above there is no danger 
of the carotid artery being wounded. If the labyrinth 
is entered through the oval window (or through the 
round window, although this possibility is denied by 
many), labyrinthitis is a natural sequence. The best way 



188 ACUTE INFLAMMATION OF MIDDLE EAR 

to avoid this accident is to familiarize oneself with the 
exact location of these structures and to avoid them when 
entering the knife, and also by brilliant illumination of 
the field and the use of as large a speculum as possible, 
to secure such a view of the drum membrane that one 
appreciates the moment the point of the knife passes 
through this structure, independent of the sensation 
communicated through the knife to the fingers. Another 
accident which fortunately but rarely occurs is facial 
paralysis, the nerve being injured by the knife as it 
sweeps upward. The writer has known of this in but one 
instance. The operation was performed by one of his 
assistants, who was a capable man. This accident may 
be avoided by not allowing the point of the knife to follow 
along the internal tympanic wall. The chorda tympani 
is not often wounded in the operation. The point of the 
knife usually passes clear of the nerve in the upward 
sweep. Ten consecutive patients tested for change in 
taste sense showed the same reactions after as before the 
operation. 



CHAPTER VII. 
MASTOIDITIS. 

ANATOMY. 

The mastoid portion of the temporal bone lies behind 
the external auditory canal, extending above to the 
squamous portion and posteriorly to the occipital bone. 
It may be regarded as a truncated wedge, the base being 
subcutaneous and the apex joining the petrous portion. 
It is in relation: above, with the middle cranial fossa; 
behind, with the posterior fossa; the posterior meatal 
wall forms its anterior surface; while below, it is grooved 
for the attachment of the posterior belly of the digastric 
muscle. Projecting downward from the outer part of the 
inferior surface is the tip of the mastoid, which is a conical 
process giving attachment to the sternomastoid, trachelo- 
mastoid and splenius capiti muscles. At the antero- 
internal border of the truncated wedge is the descending 
limb of the Fallopian canal containing the facial nerve. 

Variations. — The mastoid outlines are subject to many 
variations in position. Thus, the middle fossa may be 
very low and the posterior well forward, in which event 
there will be a small mastoid, or the converse may be 
true when a large mastoid is the result. In these large 
mastoids the tip is usually of greater size and they are, 
as a rule, of the cellular type; while in the small ones the 
bone is apt to be of more dense formation. It seems 
probable that in the development of the bone the cells 
form from the antrum into the mastoid, thus forcing 
back and arresting the encroachment of the middle and 
posterior fossae, producing the cellular type of the large 



190 MASTOIDITIS 

mastoid. Why, in one bone this process goes on until a 
large roomy mastoid is the result, while in another but 
few cells are formed and the bone remains to a large 
degree in its infantile type, it is impossible to say. The 
bone at birth contains the antrum and a few cells lying 
adjacent to it. Throughout the rest of the mastoid 
process the structure is composed mainly of diploetic 
tissue which is separated more or less completely from 
the antrum bv a denser lamina of bone. There is even 



> 





Fig. 52. — Pneumatic mastoid, cortex removed. External view. 

at this early stage a great variation in the amount of 
diploetic tissue, and therefore of the position of the sinus. 
In a mastoiditis in an infant this tissue may be com- 
pletely broken down, laying bare the sinus plate or even 
the sinus, or it may have resisted invasion. It is in this 
diploetic tissue that the cells of the mastoid are formed 
and even at this early stage of development of the bone 
its future type may be foreshadowed. x\ccording to this 
variation of the contents of the mastoid process, the bones 



ANATOMY 



191 



are usually divided into pneumatic, diploetic and sclerotic 
types. These types can be recognized more or less plainly 
at operation or upon examining dry specimens and have 
without doubt a great influence in deciding the form 
which an inflammatory process in the mastoid may take. 




Fig. 53. — Pneumatic mastoid. Superior view of ^temporal bone. 
(Mr. Burchell's dissection.) The inner table removed showing the cells 
extending well into the petrous tip. 



Pneumatic Type. — In the fully developed pneumatic 
type of bone, the mastoid cavity is completely occupied 
by cells, the septa between which are thin and shell-like 
(Figs. 52, 53, and 54). They extend into the tip, fre- 
quently back over the sinus, at times even into the occipi- 
tal bone; into the angle formed by the middle fossa and 
the recession of the sinus plate above the knee, forward 



192 



MASTOIDITIS 



into the posterior root of the zygoma and upward into 
the squama. This is a distinctly pneumatic type. On 
the other hand, one sees bones with a thick ivory-Uke 
cortex and a few cells with thick sclerotic walls, really 
a sclerotic mastoid containing a few cells. Between 
these two extremes may be found any grade in the degree 
of the cellular development of the bone. When but a 
few cells are present, it can readily be seen wiiat an 




Fig. 54. — Pneumatic mastoid, showing the interior of the mastoid process 
and the tympanum. 



influence their location will have on the direction which a 
progressive infective process will take. If they are deeply 
placed and extend from the antrum to the inferior surface 
of the bone, a purulent accumulation will find its way 
through this avenue and appear beneath the sternomastoid 
in the neck (Bezold type). If the cells extend toward the 
zygoma, the pus will appear in this locality as a subperios- 
teal abscess. These are but two instances of their effect 
upon the process, although there are many others. It 



AX ATOMY 



193 



is in these hard bones but shghtly pneumatic that one 
is more apt to encounter atypical cases of mastoiditis. 

Diploetic Type. — In the diploetic type the cortex is 
usually thicker and the mastoid and tip smaller, and in 
place of cells the mastoid is occupied by osseous tissue, 
very much resembling the diploe between the tables of 
the calvarium. As a rule there are a fe\Y small cells 




Fig. 55. — Diploetic mastoid with pneumatic spaces near the antrum. 



about the antrum between which and the surface the 
bone is hard, and below this extending into the tip the 
fliploetic tissue is found (Fig. o5). Or the bone in the 
neighborhood of the antrum may be pneumatic with a 
diploetic tip. 

Sclerotic Type. — In the sclerotic type (Fig. .*)(>) the bone 
is hard and ivory-like, but never as dense as the labyrin- 
13 



194 



MASTOIDITIS 



thine capsule. The antrum varies in size and may be 
the only cell in the mastoid. If the antrum is large, this 
is usually the case; if small, it may be so or there may be 
a few small cells adjacent to it. These bones are very 
apt to have diploetic tips. Two theories are advanced 
to explain the development of this type of mastoid. One 
is that the condition is caused by suppuration resulting 




Fig. 56. — Sclerotic mastoid with large antrum. 

in the formation of osteoblastic granulations in the cells 
of a pneumatic bone, which later form bone, obliterating 
the cells and resulting in a sclerotic mastoid. This pro- 
cess has been observed by Dixon at the New York Eye 
and Ear Infirmary by means of a*-ray plates. A series of 
exposures have been made in several patients and the 
different phases of the process shown. In these obser- 
vations the development of the sclerotic bone followed 



ANATOMY 195 

upon the resolution of an acute mastoid inflammation. 
All operators of experience have opened mastoids in 
which the cells throughout contained these large osteo- 
blastic granulations, the pus being only found when the 
antrum was opened. Such a mastoid is taking care of 
itself in a thoroughly efficient manner and may be capable 
of spontaneous cure, although the suppurative process 
in the middle ear may pass into the chronic stage. As 
the sclerotic bone is more often encountered when operat- 
ing for chronic suppurative processes, it has been assumed 
that it is the result of chronic suppuration. The obser- 
vations of Dr. Dixon tend to show that it is in the acute 
stage and while the condition is becoming chronic, that 
the change takes place; although it is a well-established 
fact that new bone formation occurs in chronic suppura- 
tion, either in the form of osseous processes projecting 
into or obliterating the antrum, or as exostoses in the 
tympanic cavity, or on the surface of the mastoid. The 
other theory, advanced by Cheatle, of London, is that 
these are infantile types of bone, that have failed to 
develop the pneumatic spaces. Probably both theories 
are true, as one meets with two types of sclerotic mastoid; 
one with low middle fossa, forward sinus groove and 
diploetic tip — a small bone which failed to develop — the 
infantile type; the other, the middle fossa is not low, 
the sinus not forward and the tip is sclerotic — this is not 
a small bone but has been sclerosed as a result of a sup- 
purative process. 

Mastoid Antrum. — The mastoid antrum is a small cavity 
which may be regarded as practically constant, situated 
at the junction of the mastoid and petrous portions of the 
temporal bone. It communicates with the vault of the 
tympanum by the additus ad antrum, which is a name 
given to the junction of these two cavities. The additus 
must not be considered as a passage, as it is not, but 
merely a name given to a certain part of one cavity which 
is formed by the tympanic vault and the mastoid antrum. 
In small antra the additus does not represent a constric- 



196 MASTOIDITIS , 

tion between the vault and antrum. In large antra which 
extend well into the mastoid, a condition not infrequently 
found at radical operations, it still must not be regarded 
as a constriction, although the antrum narrows to a 
considerable degree before it joins the tympanic vault. 
Certain pathological processes, of infrequent occurrence, 
can only l)e accounted for upon the assumption that the 
additus may be obstructed by swelling of the mucous 
membrane or granulations, so that the antrum and mas- 
toid become comi)letely se])arated from the vault. The 
antrum is in relation with the middle cranial fossa above 
separated by a thin shell of bone, the tegmen antri. The 
horizontal semicircular canal forms part of the floor of 
the antrum anteriorly, and lying upon this canal in the 
region of the additus is the short ])rocess of the incus. 

Landnidrh.— Whvn it becomes necessary to oj>en the 
antrum it may be located in the following manner: first 
draw a line tangent to the u])per canal wall, then one 
tangent to the ])()steri()r wall. These imaginary lines 
map out a triangle (the Dench triangle) of which they 
form two sides, the base being formed by the wall of the 
meatus. In this triangle at a (le])th of about one-half 
inch, lies the antrum. In this triangle there is often found 
a small sjMke-like process, the spine of Ilenle. This is 
taken by some operators as a guide to the antrum; but 
as it often projects from the extreme margin of the 
entrance to the osseous meatus, and as it is far from 
constant, it is less reliable as a guide than the triangle 
as described. Another method of laying out a triangle 
is that of jNIacEwen. The lower temporal ridge forms its 
upper limit, the posterior margin of the meatus, its 
anterior boundary, while the third side is an imaginary 
line connecting these two. It is not an infrequent occur- 
rence to find either the sinus or floor of the middle fossa 
encroaching upon this triangle, and it is therefore less 
reliable than that of Dench. 

Middle Fossa. — In operating upon the mastoid two other 
points are of great importance — the location of the middle 



ANATOMY 197 

fossa and the lateral sinus. The middle fossa may lie as 
low as the superior wall of the osseous meatus, or it may 
be considerably higher, but one never knows until the 
mastoid is opened and its configuration seen. So the 
possibility of its occupying a low position should always 
be borne in mind. 

Lateral Sinus. — The lateral sinus lies on the cerebellar 
surface of the mastoid in a groove traversing the bone 
from above downward. The depth of this groove and 
the location of the sinus present great variation. The 
sinus may be found in some instances as far forward as 
the posterior wall of the canal or lie much farther back, 
say an inch in some instances, and between these extremes 
any position may be occupied. It varies also as to its 
depth from the surface of the mastoid. In some instances 
there is but a thin shell of bone between the sinus and 
surface of the mastoid. If in such a condition it lies far 
forward also, it is in danger of being wounded in the 
mastoid operation. Fortunately this configuration is 
somewhat rare, but must be borne in mind. In other 
subjects the sinus lies more deeply, so that numerous 
cells exist between it and the mastoid cortex, and between 
these two extremes all grades of variation occur. There 
are no landmarks upon the surface of the bone by which 
its position can be determined, so the mastoid should 
always be opened carefully as though the sinus occupied 
an anterior position until, as the operator progresses, it 
is found not to do so. The skiagraphic plates of the 
mastoid process afi*ord some information as to the location 
of the sinus, but too much reliance must not be placed 
upon their readings. 

Mastoid Process in Infants. — At birth the antrum and a 
few cells contiguous to it are found, but they apparently 
lie a trifle higher in the bone and much nearer the sur- 
face. The overlying cortex is much softer, so that in 
many instances a suppurati\'e process will perforate the 
bone and the pus finds an exit on the surface of the mastoid 
rather than, l)y rupturing the drum meml)raMe, appear 



198 



MASTOIDITIS 



in the canal. The drum head lies on the surface and the 
canal is membranous. There is no tip, the facial nerve 
appearing on the external mastoid surface at the junction 
of its inferior and anterior border. The fossa subarcuata 
(or floccular fossa) exists as a well-marked depression 
beneath the superior semicircular canal (Fig. 57). This 
is lined with dura mater and through it bloodvessels pass 
to the mastoid antrum. In achilt Hfe this is obHterated 
to a mere fissure containing a process of (hira mater and 
a small vein. Through this aveiuie infection may travel 




Fig. 57. — Posterior and internal view of the temporal bone of an 
infant, showing the floccular fossa or fossa subarcuata. The dark opening 
to the left is the internal auditory meatus. 

from the mastoid to the meninges. The parts of the bone 
are not so firmly joined in children as in adults and 
through these but shghtly soHdified fissures there are 
vascular communications which allow infection of the 
intracranial structures to more readily take place. The 
development of the mastoid occurs quite rapidly, so that 
before the end of the first year the osseous meatus can be 
made out as a distinct depression, while in a child between 
three and five years one is often impressed with the close 
resemblance to the adult bone in all respects except size. 



MASTOIDITIS 199 



MASTOIDITIS. 

Definition. — Mastoiditis is an inflammation of the mas- 
toid process. As might naturally be expected in a bone 
presenting so many variations in structure, the form 
which the inflammation assumes varies considerably 
both in its location and clinical manifestations. The 
bone is covered with periosteum and there seems no 
reason why a localized periostitis might not develop. 
While one can conceive that such a process could be due 
to causes outside of the ear, this is practically never the 
case, and as a subperiosteal accumulation of pus is so 
often seen secondary to middle-ear and mastoid involve- 
ment, in fact part of the process, it is as well to dismiss 
from one's mind these remote possibilities. As much 
may be said of primary involvement of the mastoid 
process, that is, not secondary to middle-ear disease. 
There seems no reason why the mastoid may not be the 
seat of an osteitis the same as any of the other bones. 
Cases are reported in which this is supposed to have 
occurred, the infection, usually tubercular or syphilitic, 
reaching the bone through the blood stream or lymphatics. 
As mastoiditis in tuberculosis and syphilis commonly 
arises from middle-ear infection, if the process in the 
mastoid was associated with middle-ear disease, it would 
naturally be attributed to it. The mastoid may also be 
infected from a penetrating wound or some other form 
of traumatism. In this case the process might possibly 
stop short of involvement of the middle ear and antrum, 
but it is probable that these cavities would as a general 
rule take part in the process. Moreover, the treatment 
in these very rare processes would be along the same 
lines as in those which are constantly coming under 
observation. Therefore it is sufficiently accurate to 
define mastoiditis as an inflammation of the mastoid 
process due to infection and secondary to involvement of 
the middle ear. 



200 MASTOIDITIS 

Causation. — The infection, as has been shown, usually 
reaches the middle ear through the Eustachian tube, 
although it may do so through a perforation in the mem- 
brana tympani. Moreover, as the path of infection is 
through the antrum, the process which causes the mas- 
toiditis must involve the vault. This renders it neces- 
sary that the primary process should be a purulent one, 
either an acute suppurative otitis media or an acute 
exacerbation of a chronic process. Therefore the etiology 
of mastoiditis becomes the same as that of O. j\I. P. A. 
If the vault is involved, the antrum must be involved 
also, as they are only parts of the same cavity. It is 
pr()bal)le that some of the mastoid cells contiguous to 
the antrum are involved in almost every case of O. ]\I. 
P. A. in which the vault is invaded. Whether or not 
the process extends farther than this depends U])()n the 
promptitude with which drainage is established and its 
sufficiency, the character of the bone, the nature of the 
infection, and the resistance of the patient. The pressure 
of the accumulating secretion forces the infection farther 
into the mastoid cells if they are present. If the bone 
is sclerotic, the cells cannot be invaded, thus giving some 
relief to the pressure; so it not infrequently occurs that 
the pus escapes through the Rivinian segment and appears 
on the surface of the mastoid as a subperiosteal abscess. 

Pathology. — The first stage of the involvement of the 
cells is a congestion and exudation of serum which may 
extend throughout the mastoid or be limited to a part 
of it. In this stage there is no breaking down of the septa 
between the cells. Politzer has shown that there are 
communications between the cells through which the 
process readily extends. The lining of these pneumatic 
spaces is a modified mucoperiosteum, but it is capable 
of great inflammatory reaction. If a mastoid is opened, 
which is in this stage of inflammation, no pus will be 
found, but the cells will be red and filled with serum which 
is usually more or less tinted with blood. Following this 
stage with more or less rapidity, according to the activity 



MASTOIDITIS 201 

of the process, is the formation of pus. If such a mastoid 
is opened, the cells are filled with pus but the septa seem 
intact. In the third stage, the septa between the cells 
break down and granulations are formed which are not 
osteoblastic in nature. One occasionally opens a mastoid 
where granulations have formed in cells with intact 
walls. They may be found in a part of the mastoid only, 
usually that part farthest from the antrum, while the 
rest of the mastoid is in any of the three stages above 
described. They are no doubt osteoblastic in nature 
and represent an effort at repair and limitation of the 
process by the formation of new bone. When they 
occur in a mastoid in which the remaining pneumatic 
spaces are filled with serum, it doubtless indicates that 
the condition is either in process of, or capable of, resolu- 
tion. After the septa between the cells are broken down 
and an abscess formed, the pus exists in sufficient amount 
to render drainage through the tympanum practically 
impossible no matter how large the defect in the mem- 
brana tympani. Besides the process is of such a nature 
that the breaking down of bone seems to be a part of it. 
So as this pus accumulates it comes to the confines of the 
mastoid process and ruptures through them. 

Location of Rupture. — According to location these 
ruptures may take place as follows: 

1. Through the inner table. This structure in some 
bones is very thin and offers little resistance to the invad- 
ing process. If the pus breaks through in the middle 
fossa, it produces what is termed an extradural abscess 
(also called epidural abscess) ; if into the posterior cranial 
fossa the condition is the same, only, as such abscesses 
are usually in the region of the sinus and have this struc- 
ture as one of their walls, they are spoken of as perisinus 
abscesses. When the pus accumulates between the dura 
(or sinus wall) and the inner table, the external layers 
of the dura react by the formation of granulations. The 
size of these seems to depend largely upon the duration 
of the process, being found in some operations very small. 



202 MASTOIDITIS 

as though just beginning to form; in others, which have 
been long deferred, they are very large. In two patients 
upon whom the author operated and in whom the mas- 
toiditis had existed for more than six months, these granu- 
lations were found to be over one-half inch in thickness, 
springing from the wall of the sinus and practically 
filling the mastoid cavity. The infection in one instance 
was the Streptococcus capsulatus, in the other the pneumo- 
coccus, but complete recovery ensued. 

2. Cortical Perforations, — The i)us in the mastoid may 
rupture through the cortex of the bone on the outer sur- 
face. This occurs more often in children. In adults 
the cortex is usually thicker and resists the process. 
Nevertheless, a cortical perforation in an adult is far from 
a rare occurrence. The most common location is directly 
over the antrum, but no ])art of the bone is exempt. The 
pus after finding its way through the softened bone accumu- 
lates beneath the periosteum, which it strips to a greater 
or less extent from its osseous attachment. One form of 
this perforation is through the cortex covering the zygo- 
matic cells. In this form two types are seen. If the pus 
breaks through c()mi)aratively low and more ])()steriorly, 
it dissects the periosteum from the bone above and behind 
the ear, obliterating the fold between the auricle and the 
side of the head, thus forcing the former to stand away 
from the head. In the other type, the perforation being 
more forward and higher, the pus is prevented from 
spreading backward by the attachment of the temporal 
fascia and accumulates beneath the muscle in the form of 
a "deep temporal abscess." 

3. Rupture may occur through the anterior surface 
of the bone, which is also the posterior wall of the external 
auditory meatus (or premastoid lamina) appearing in 
the canal as a subperiosteal swelling. In this, as well 
as in ruptures on the external surface of the bone, the 
skin and other structures overlying the periosteum may 
become inflamed and break down and the abscess thus 
discharge externally. 



MASTOIDITIS 203 

4. The rupture may occur on the inferior surface of the 
bone internal to the tip. In this event the pus accumulates 
beneath the muscles attached to the tip in the form of a 
deep-seated abscess (Bezold's type). 

Symptoms. — Mastoiditis, being constantly associated 
with otitis media, it is often difficult to determine what 
part of the clinical raanifestations is due to the mastoid 
involvement. It is well to consider every patient who has 
an O. M. P. A. affecting the vault as having mastoiditis 
also. The mastoid involvement may never pass beyond 
the first stage, its progress being checked by the estab- 
Hshment of drainage of the vault and antrum. It is then 
capable of resolution, while if it progresses to the forma- 
tion of pus and the breaking down of cells, an abscess is 
formed and the process cannot resolve. Some authors 
call the first form mastoiditis and the second mastoid 
abscess, and it must be conceded that there is much in 
favor of this division. 

Pain. — Pain may be considered as an almost constant 
symptom of mastoiditis. It varies greatly in the degree 
of its severity and in its duration. It may be nearly or 
quite absent in processes due to infection with the Strep- 
tococcus capsulatus, and is generally mild or absent in 
tubercular involvement of the mastoid. In the early 
stage of an O. ]\I. P. A. before drainage has been estab- 
lished the mastoid involvement intensifies the pain. 
It is frequently excruciating and boring in character, and 
keeps the patient awake at night; but as spontaneous 
rupture takes place or the drum membrane is incised it 
usually begins to subside. Exceptionall\', the estabHsh- 
ment of drainage seems to have very little eftect upon it. 
If pain is not relieved under these circumstances, it is 
fair to assume that the disease is progressing. Sometimes, 
after having subsided and remained absent or very mild 
for several days or a week, or even longer, pain again 
becomes severe. This is a symptom strongly indicati\e 
that the process has passed into the operative stage. 
In some patients the pain is mikk^, but they complain 



204 MASTOIDITIS 

of a vague discomfort in the mastoid region. This is 
more apt to be a later symptom, occurring usually in 
the operative stage. 

Tenderness on Pressure. — Tenderness on pressure over 
the mastoid is one of the commonest symptoms of mas- 
toiditis and may occur at any stage of the disease. It 
may be absent, as it frequently is in processes caused by 
the Streptococcus capsulatus. Before drainage is estab- 
lished the mastoid may be very tender, but this often 
diminishes together with the spontaneous pain after 
incision or rupture of the drum membrane. If the process 
is resolving, it gradually diminishes, being less from day 
to day until in a week or so it is absent; or, it may only 
remain a day or so. Or it may not appear until the 
middle-ear suppuration has existed for a week or more. 
It then has a far dittVrcnt significance than when it is 
an early symptom and is almost certain to be associated 
with mastoid al)scess. A great deal has been written 
about the significance of the diflcrcnt locations of the 
mastoid tenderness. The author is not convinced that 
much of value may be inferred from the fact that the 
tenderness is in one place rather than in another. It is 
doubtless due to congestion of the periosteum and under- 
lying bone and indicates that the process within the 
mastoid approaches the surface in the locality in which 
it is found. In a patient with a very thick cortex, it is 
more apt to be absent or come on later. Care should 
be taken in eliciting mastoid tenderness not to move the 
auricle or external auditory canal with the thumb which 
is applied to the mastoid, as this produces pain in inflam- 
matory conditions of the meatus. In normal persons 
there seems considerable variation in the amount of 
tenderness on pressure upon the mastoid. Many sub- 
jects wince when firm pressure is exerted upon the tip; 
so not too much force should be used and the opposite 
side examined for comparison. 

Fever, — In many adults there is very little rise of tem- 
perature. In others, there may be several degrees of 



ji 



MASTOIDITIS 205 

fever. It rarely rises above 102° F., and even at this 
point one would begin to suspect the presence of compli- 
cations; while if it reached 103° F. one would look for its 
cause outside of the mastoid. It is different in the case 
of children. In them fever is the rule until the pus breaks 
through the mastoid cortex, when it may subside. A 
temperature of 103° or 104° F. in young children is not 
uncommon, while in infants it may reach 105° F. Often- 
times temperatures which are not due to the mastoid 
condition are attributed to it. A complicating pneumonia 
not rarely occurs in children and if it gives no signs a 
very puzzUng situation may arise, especially if the ques- 
tion of operation rests upon the temperature. Every 
aurist of experience has been called to operate upon the 
mastoid of these little patients, on the mistaken idea 
that the mastoiditis was the cause of the fever. 

Discharge. — The discharge sometimes gives one an 
intimation of the presence of mastoiditis. If it increases 
in amount so that it could not be produced in such a 
limited space as the tympanum and antrum, it probably 
comes from the mastoid. If it suddenly ceases, with an 
increase or no amelioration of the other symptoms, to 
appear again after a more or less extended interval, one 
suspects mastoid abscess. In some patients the character 
of the pus and the fact that it is flowing quite freely so 
long after the inception of the disease, cause one to sus- 
pect that a mastoid abscess has formed. This is especially 
true in capsulatus infections. The patient may not have 
pain or other symptoms, the pus being fairly abundant 
and of a peculiar creamy nature; upon bacteriological 
examination the prevailing organism is found to be the 
Streptococcus capsulatus. If this occurs in the third 
week or later, an operation is indicated; if in the second, 
an .r-ray examination, if positive, indicates operation. 

There is, however, a type of mastoiditis which may be 
considered as more or less subacute in nature, occurring 
usually in infants and children, in which the discharge 
continues very free into the fourth week or even later. 



206 MASTOIDITIS 

notwithstanding the removal of the adenoids and tonsils. 
Constitutional impairment arising from the suppuration 
may be present or apparently absent. When these 
mastoids are opened, they are usually found completely 
broken down, filled with pus and granulations, with the 
sinus plate and inner table intact. Tympanic drainage 
has apparently been adequate to prevent the occurrence 
of tension sufficient to cause rupture of the pus through 
the confines of the mastoid, although to increased tension 
may reas(ma})ly l)e attributed attacks characterized by 
a slight rise of temperature acc()m])anied by restlessness 
from wliich these ])aticnts occasionally sutt'er. A mastoid 
operation is justifiable in this type of case, not only to 
relieve the juitient from his sym])t()ms, but also to prevent, 
if possible, the discharge from becoming chronic. 

Closely allied to these are recurrent attacks of suppura- 
tion not infrequently ()l)served in children. An attack 
of (). jM. p. a. occurs and after a short j)eri()d the discharge 
ceases. The mcmbrana tym])ani may or may not become 
normal. Another attack occurs in from two weeks to 
three months and then another and so on, the nutrition 
and development of the child finally suffering to a consider- 
able extent. While doubtless some of these processes are 
due to adenoids and tonsils giving rise to infection through 
the tube, many are caused by the i)ersistence of a focus 
of infection in the mastoid, and, if relief is not obtained 
after removal of the adenoids and tonsils, a mastoid 
operation should be performed to remove this focus of 
infection 

Fundu.s Changes. — There will be present in the mem- 
brana tympani characteristic changes of the accompany- 
ing otitis media. This will usually be all that may be 
seen during the first week of the disease. Later a certain 
characteristic fundus change occurs and may be con- 
sidered as indicating with certainty that the process has 
passed the stage in which resolution is possible, in fact, 
indicates operation. This is a swelling of the postero- 
superior wall of the canal contiguous to the drum mem- 



t 



MASTOIDITIS 207 

brane. The canal at this location overlies the antrum 
and the swelling is due to the process within the mastoid. 
In extreme instances, the canal may be so narrowed that 
a view of the anterior and lower part of the membrane 
becomes impossible. As usually developed the sagging 
is quite apparent when compared with the opposite side 
and extends into and includes the contiguous part of the 
drum membrane. Conical perforations are very frequently 
associated with mastoiditis in the later stages, and 
should always direct one's attention to the probability of 
mastoiditis. A condition to which Dr. Dench has called 
attention, having nearly the same significance as sagging 
of the posterosuperior wall, is a shortening of the 
canal from a prominent position of the drum membrane. 
This structure has a dull red, thickened appearance and 
while the natural depression of the membrane is absent, 
there is no local bulging. The whole membrane including 
Shrapnell's is moved toward the canal, giving the impres- 
sion that the canal is not as deep as on the opposite side. 
It is produced by granulations in the tympanum and is 
a later sign usually indicating that the stage of resolution 
is passed. 

Thickening Over the Mastoid — Edema and inflamma- 
tory thickening over the mastoid is not infrequently 
seen and is due to the approach of the inflammation in 
the mastoid to, and involvement of, the cortex. In adults 
it usually precedes the rupture of pus through the cortex, 
but in children this often takes place without being pre- 
ceded by noticeable edema or thickening. As other 
diseases may produce this condition, it becomes a valuable 
indication when they are excluded and then shows that 
the process has passed the stage at which resolution is 
possible. 

Subperiosteal Abscess, — Subi)eri()steal accumulations of 
pus often occur, especially in chiklren. In these swellings 
deep fluctuation can usually be detected. The skin and 
tissues over them may be red and inflamed or seem not 
markedly changed. When they occur above and behind 



208 MASTOIDITIS 

the ear, a characteristic appearance is produced. The 
auriculocranial fissure is obUterated and the ear stands 
away from the head (Figs. 58 and 59), and frequently 
seems lower than on the opposite side. If they are 
limited to the temporal fossa (deep temporal abscess), 
the ear may have this appearance but to a less marked 
degree, and fluctuation, while not so plain, can usually be 
elicited. If they occur more posteriorly on the mastoid 
surface or near the tip, the position of the auricle is not 




Fig. 58. — Subperiosteal abscess. Anterior view. (Posey and Wright.) 

changed so much, if at all. In Bezold's type of mastoid- 
itis, the abscess does not remain confined between the 
bone and periosteum, but ruptures beneath the muscles 
attached to the tip, producing an oval ill-defined swelling 
in the neck adjacent to the mastoid. 

Stiftness of the neck due to rigidity of the muscles 
attached to the tip is occasionally seen. Torticollis is a 
somewhat rarer symptom. 

Diagnosis. — As mastoiditis is so constantly associated 
with an acute suppurative process involving the vault, 



MASTOIDITIS 



209 



the diagnosis narrows itself down to determining in what 
stage is the process, and whether or not an operation is 
indicated. To recapitulate, the symptoms and signs 
given above are: (1) spontaneous pain; (2) tenderness 
on pressure; (3) fever; (4) change in the discharge; (5) 
fundus changes; (6) swelling of the soft parts and edema; 
(7) surface abscesses. It is not often that one is called 
upon to make a diagnosis upon any single one of these 




Fig. 59. — Characteristic appearance in subperiosteal abscess adjacent 
to the external auditory canal. Posterior view. (Posey and AVright.) 



symptoms and signs, although some of them are so 
characteristic that if present he may safely do so and test 
his diagnosis if necessary by operation. Spontaneous 
pain, tenderness on pressure, and fever, are the only ones 
in the list that are seen in the first stage when the process 
is capable of resolution, although they may be seen in the 
later stages and cause one to operate. These symptoms 
when they occur early, before drainage is established, 
14 



210 MASTOIDITIS 

have a far different significance than when they occur 
in the second week or later, when they are often asso- 
ciated with fundus changes also. The duration of the 
process is dated from the appearance of pain or fever in 
the accompanying O. j\I. P. A. If a patient has a very 
tender mastoid at the time drainage is established, per- 
haps associated with fever and pain, and this tenderness 
gradually diminishes during the first week and at the 
same time the pain and fever become less, as they usually 
do, the process is resolving. No matter how tender the 
mastoid during the first week, if it is becoming less so, 
one need not operate. If this tenderness after diminish- 
ing for a w^eek then begins to increase, or returns after 
being absent, then there is probably a process incai)able 
of resolution. If one finds in addition a sagging of the 
posterosuperior wall, operation is necessary. If not the 
.r-rays may throw some light on the sul)ject. One does 
not feel inclined to o])erate on tenderness alone, although 
at times he may safely do so. It is a subjective symi)t()m 
and is occasionally exaggerated by the patient. More- 
over, in affections of the nerves supplying the mastoid 
integument hyperesthesia may be marked. One then is 
apt to find that the tenderness is not limited to the mas- 
toid process. There is one type of case in whicli the pain 
is very intense and remains so notwithstanding a free 
myringotomy. When the mastoid is opened, the cells are 
found to be filled with blood. This hemorrhagic form of 
mastoiditis is not common, but an earl}' operation is 
justifiable. Then again, fever may make an early opera- 
tion the proper procedure. But one must satisfy himself 
that there is no other cause for the rise of temperature 
except mastoiditis, or some complication arising from it. 
At times the most skilful internist fails to find the cause 
of a rise of temperature, and to attribute it to the mastoid 
because the drum membrane does not appear normal or 
there is a discharge is manifestly unfair. On the other 
hand, one must not err in the opposite direction and delay 
operation if the mastoid is the cause of the fever. During 



MASTOIDITIS 211 

the first week in such an instance, when tenderness on 
pressure if present would be a great aid, it may be absent 
or its exact amount determined with difficulty on account 
of the patient being a child or infant. When the fever 
occurs later, other evidences of mastoiditis are apt to be 
present and the decision becomes easier. An infant or 
young child is very apt to develop a subperiosteal abscess 
early in the disease. This may indicate that the cause 
of the fever was in the mastoid. As compared with the 
number of operations upon subperiosteal abscesses in 
these little patients, those necessary when this condition 
is not present are probably in the minority. 

If there is narrowing of the fundus from sagging of the 
canal wall, it will usually be associated with some of the 
other s^TQptoms or signs, but if it occurs alone in an O. M. 
P. A. of ten days' duration, it indicates a mastoiditis 
incapable of resolution and therefore operation. A sub- 
periosteal abscess is diagnosed by the elicitation of fluc- 
tuation; and if it occurs above and behind the ear, the 
characteristic position of the auricle, which stands away 
from the head, obliterating the auriculocranial fold. 
This appearance does, at times, occur with furuncle, 
but the swelling in furuncle is more apt to be edematous 
and pit on pressure and very rarely gives the sense of 
deep fluctuation. iMovement of the auricle is painful in 
furuncle, and only rarely so in subperiosteal abscess. 
Moreover, examination of the meatus ought to enable 
one to decide. When the abscess is located upon the pos- 
terior canal wall, it may resemble furuncle very closely. 
(For differential diagnosis see Furuncle.) Edema or infil- 
tration of the tissues over the mastoid, if one can be cer- 
tain that the condition is due to a process within this 
structure, establishes the diagnosis of mastoiditis of 
operative type. Usually, however, one finds some of the 
other signs or symptoms present, such as narrow fiuidus, 
profuse discharge, etc. Every swelUng of acute nature 
occurring in the mastoid region should be looked upon 
with suspicion and investigated by operation in case of 



212 MASTOIDITIS 

doubt. An enlarged broken-down gland often resembles 
the tumefaction due to mastoid disease. These inflamed 
glands do not usually cause the auricle to stand away 
from the head so markedly, and they are more apt to be 
situated lower than the condition resembling them due 
to mastoiditis. The proper procedure is to make an 
incision through them to the bone, then if the pus is 
beneath the periosteum, open the mastoid; if this mem- 
brane is normally attached, refrain from doing so unless 
for some other reason the operation is indicated. 

The author has reported^ four cases in which the middle 
ear was apparently normal and yet mastoiditis was present, 
the infection probably ])assing through the tym])anum 
and reaching the mastoid, the membrane in the additus 
swelling and separating these cavities, after which the 
process continued in the mastoid while the middle ear 
cleared up, so that when coming under observation it 
appeared normal. In three of these i)atients a subperios- 
teal abscess indicated the nature of the process; while 
the fourth patient was seen in a dying condition and the 
autopsy showed the presence of sinus thrombosis and 
meningitis secondary to mastoiditis. In all j)atients 
where the diagnosis of mastoiditis is at all doubtful, an 
.r-ray plate should be made and interpreted by one who 
has experience in this work. ^Mastoiditis occurring as 
an acute exacerbation of a chronic suppurative process 
always indicates immediate operation. 

Prognosis. — In a great many patients who have mas- 
toiditis in the early stages of an O. M. P. A., the process 
gets well during the first week or so. Some, however, 
pass into the stage in which resolution is impossible and 
operation is necessary. But the mortality of the opera- 
tion in uncomplicated cases is very small. When sinus 
thrombosis, meningitis or brain abscess are caused by 
the mastoid infection the prognosis naturally becomes 
grave. The outlook is influenced by the general condition 

1 Annals of Otology, St. Louis, June, 1911. 



MASTOIDITIS 213 

of the patient as well as the nature of the infection. Dia- 
betes with between 3 and 4 per cent, of sugar, especially 
if the urine contains acetone, makes the prognosis very 
serious. These patients seem more apt to have Strepto- 
coccus capsulatus infections. This germ is considered 
to indicate that the process is more grave, and this is to 
a certain extent true. Still the large majority of the 
patients with this infection make good recoveries. On 
the whole the prognosis of mastoiditis is good, but, in 
view of the ever-present danger of sinus thrombosis, 
meningitis and brain abscess, one should be more or less 
guarded in expressing an opinion. 

Treatment. — The best preventive treatment is an early 
and free incision of the drum membrane, the cut extend- 
ing into ShrapnelFs. If this is done the inflamma- 
tory process, as far as possible, is minimized, perhaps 
only a few cells contiguous to the antrum becoming 
involved. A free incision of the membrana tympani is 
also the best treatment to be adopted after symptoms 
referable to the mastoid have developed. If spontaneous 
rupture has occurred and drainage does not seem sufficient, 
a m^Tingotomy should be done. In these incisions after 
mastoid symptoms have declared themselves, the knife 
should be passed well into Slii^apnell's membrane and 
withdrawn on the posterosuperior wall dividing the tis- 
sues to the bone for about one-fourth inch from the mem- 
brana tympani. This is practically the only treatment 
from which much may be expected. It is well, no doubt, 
to put the patient to bed and order a cathartic. The 
discharge is syringed from the canal as in O. ]M. P. A. 
It is well to determine in every patient the nature of the 
prevailing germ of the infection; also, to keep a chart 
of the temperature. The patient should be examined 
from day to day to note the progress of the disease. If 
thought desirable, cold in the form of the ice-bag or Leiter 
coil may be applied. It will frequently make the mastoid 
less tender and relieve the spontaneous pain but probably 
has very little influence for good upon the disease. All 



214 MASTOIDITIS 

are agreed that cold applications should not be persisted 
in for more than twenty-four hours, as by masking the 
pain and tenderness they serve to keep one in ignorance 
of the progress of the disease. The same may be said 
of any of the preparations of opium. Pain being one of 
the symptoms by means of which one determines whether 
or not the disease is improving, it is very unwise to mask 
it in any way, as its absence or mikl character, due to the 
anodyne, might cause an unjustifiable postponement of 
operation. The use of cups, after scarification, or of 
leeches, artificial or living, is only to be condemned. They 
are probably of no vahie and only interfere witli the proper 
elicitation of mastoid tenderness by the soreness which 
they cause. One cannot tell how much pain on pressure 
is due to the disease and how much to the treatment. 
For the same reason all a])])Hcati()ns which render the 
parts sore, such as rubefacients, blistering ointments 
and other remedies, should be absolutely prohibited. 
The Baer hyj^eremia treatment is ])robably without 
value. One must remember that an abscess is forming in 
bone and that nature has i)rovided for a certain amoimt 
of drainage which nuist be encouraged and increased if 
possible. If this drainage is sufficient, combined of course 
with good resistance on the ])art of the patient, the 
process will resolve. The siu'geon after seeing that tym- 
panic drainage is as free as can be made, simply waits, 
as nothing which he can do further can reasonably be 
expected to influence the disease. He must bear in mind 
the proximity of vital structiu'es and the danger of com- 
plications, and open this bony abscess as soon as he 
becomes satisfied that resolution is impossible or complica- 
tions occur or seem imminent. 

MASTOID OPERATION (SCHWARTZE). 

Instruments. — There is a great deal of variation in the 
number and design of instruments required by ditterent 
operators in performing the mastoid operation. While 



MASTOID OPERATION 



215 



it is always well to have an instrument at hand when 
needed, too many are to be avoided both on account of 
the expense and the fact that finding any instrument 
required on a table too well supplied with them only 
takes time and trouble. The following list comprises 
the ones the surgeon is almost certain to need before the 
operation is finished, and they are also sufficient to enable 
one to perform any mastoid operation properly. 

1. A knife for the incision. A full-bellied scalpel of 
good size is the best type. 

2. A number of hemostat forceps. Between six and 
twelve will be required. 

3. A periosteal elevator. These are made hoe-shape, 
but the form shown in the cut (Fig. 60) will be found 




Fig. 60. — Author's periosteal elevator. 

preferable. With it one can elevate the periosteum either 
forward or backward, and it is very useful in separating 
the muscles from the mastoid tip. 

4. Retractors. — If the surgeon can have an assistant to 
hold retractors, those designed by Dr. Whiting are the 
best. If not, one of the self-retaining retractors such as 
Alport's or Yansen's are very useful (Fig. 61). 

5. Gouges. — A set of three gouges designed by the 
author are advised. They are sharpened by a bevel on 
the anterior surface, which enables any desired thickness 
of bone to be removed without previously setting them 
as in instruments bevelled posteriori}^ (Fig. 62). 

6. A mallet. These are made of rolled raw hide or 
lignum vitie. 

7. A set of three curettes (Spratt's). The larger, medium 



216 



MASTOIDITIS 



and smaller-sized curettes (Fig. 63). The largest size is 
very safe to use when curetting the cells lying on the 
inner table either in the middle fossa or over the sinus 




Fig. 61. — Yansen's self-retaining mastoid retractor. 



Fig. 62. — Author's mastoid gouges and chisels. 




Fig. 63. — Spratt's mastoid curettes. 



MASTOID OPE RAT I OX 



217 



plate; the medium in breaking up individual cells and 
curetting in the depth of the mastoid between the sinus 
and posterior canal wall. The smaller one is useful in 
curetting around the antrum and zygomatic cells in the 
manner to be described. 




Fig. 64. — Mathieu's rongeur forceps. 



8. Three pairs of thumb forceps. One plain-pointed, 
for the assistant to use in sponging and in picking the 
chips out of the wound, as they are made by the operator's 
gouge or curette. The other two, mouse-toothed, for 
approximating the edges of the wound. 




FULL SIZE 

Fig. 65. — MacKernon's rongeur forceps. 



9. Two pairs of rongeur forceps. One [Mathieu's 
(Fig. 64) to remove overhang as it is formed by removal 
of underlying cells with the curette, and also to remove 
the tip. One ^MacKernon's (Fig. 05), which will be found 



218 



MASTOIDITIS 



useful when it is necessary to remove the inner table 
while enlarging an exposure of the dura or sinus. 

10. Two probes — large and small size — and a grooved 
director. 




Fig. 66. — Scheibel's suture forceps. 

11. A pair of scissors curved on the flat — used ])riiici- 
pally in freeing the tip. 

12. Michel's clamps and forceps for j^lacing them in 
position (Figs. ()(> and ()7). 



0CL3@ 



Fig. 67. — Michel's nietiil claiup suture. 



Preparation of Patient. — When possible, it is always 
better to prepare the i)atient for operation by a cathartic 
the night before and a light breakfast and no lunch, if 
the operation is to be performed in the afternoon, or 
without any breakfast, if in tlie forenoon. If local anes- 
thesia is used, these precautions in diet are not neces- 
sary. If a diabetic has an acute purulent otitis media, 
it is well to put him on a diet at once, that he may better 
stand the mastoid operation should it become necessary. 
Unfortunately, but too often, the patient comes under 
observation when an operation is imperative and no 
time for preliminary treatment is afforded. Several 
hours before the operation the parts around the ear 
are shaved, thoroughly scrubbed with soap and water, 
washed with bichloride solution, then with alcohol. 
The ear is thoroughly syringed with bichloride solution, 
1 to 5000, and a piece of sterile packing inserted. The 
parts are then covered with a sterile dressing. When 



MASTOID OPERATION 219 

the operation is an emergency one, these preparations are 
made immediately before the patient is placed upon the 
table. At the New York Eye and Ear Infirmary patients 
are continually presenting themselves at the afternoon 
clinic in such a condition that an immediate mastoid 
operation is imperative and they are frequently admitted 
to the wards, prepared, and the operation begun within 
an hour from the time they have come under observation. 

Anesthesia, — A general anesthetic is regularly used. 
While it is perfectly possible to perform a mastoid opera- 
tion under local anesthesia, it has never become at all 
popular. The shock caused by the impact of the mallet 
on the gouges, the scraping with curettes and the crunch- 
ing of the rongeur, all produce an effect upon the sen- 
sorium of the patient which more than offset an}^ advan- 
tage derived from local anesthesia. Gas and ether are 
usually used, although if there are any pulmonary com- 
plications, gas and oxygen is safer. The patient may be 
anesthetized after being placed on the table or in an 
adjoining room and placed upon the table after going 
under. 

Position of Patient. — ^The patient being on the table 
and under anesthesia, a sand-bag is placed beneath the 
neck and side of the head, the face being directed toward 
the side of the table corresponding to the good ear, the 
bandages are removed and a double towel slipped under 
the head. The two ends of the upper towel are then 
brought up over the head overlapping each other and 
pinned. A towel folded lengthwise is then placed in 
front of the ear, reaching from the one above to which 
it is fastened to well on the chest. Another posteriorly 
diverging from this one sufficiently to expose the field 
of operation. Immediately below the ear, and connect- 
ing these two, another towel is placed. The field of 
operation is painted with tincture of iodine and wiped 
with gauze saturated with alcohol. This treatment of the 
field seems to have an influence in preventing erysipelas 
and skin infections. The anesthetist sits at the side of 



220 MASTOIDITIS 

the table well out of the way. The surgeon stands at the 
head of the table and his first assistant, who is to sponge, 
at the side, during the first stages of the operation; later 
they may change places if necessary. If an assistant 
holds retractors, he stands between the operator and 
anesthetist. The instrument table is just back of the 




Fig. G8. — Incision in the mastoid operation. 

space between the operator and his first assistant and 
convenient to both. 

Incision. — The position of the lower end of the mastoid 
tip is located by palpation and the incision is made begin- 
ning at this point and extending to above the auricle, 
passing about one-fourth of an inch posterior to this 
structure (Fig. 68) and curving forward at its upper end. 



MASTOID OPERATION 



221 



The incision is made to the bone in its middle part. 
Here the bone is practically subcutaneous, while at the 
upper end it is covered with the temporal muscle and 
fascia, and at the lower end to a greater or less extent 
by the muscles having their insertion at the tip. If the 
incision is not curved forward at its upper end, it passes 
directly into the temporal muscle, and this structure 
will be needlessly cut; and besides, it may be very diffi- 
cult to secure sufficient exposure to remove the zygomatic 
cells. 




Fig. 69. — Anterior flap elevated and held forward Avith retractor. The 
Dench triangle is marked upon the bone. 



Exposure of the Field. — The bleeding points are now 
caught with hemostats and with the periosteal elevator 
the anterior flap is separated from the bone and pushed 
forward until the posterior and part of the superior bor- 
ders of the opening of the bony meatus are brought into 
view (Fig. 69). Care should be taken not to make a 
perforating wound of the membranous canal. The anterior 
retractor is now inserted. The temporal muscle is pushed 
up with the elevator, thus affording a view of the lower 
part of the squama. 



222 MASTOIDITIS 

Exposure of the Tip, — The tip is now ''freed" by detach- 
ing the muscles inserted to it. This may be done with 
the elevator by scraping the muscular attachments from 
the bone, or scissors curved on the flat may be used. In 
either method, one works downward and inward carefully 
so that after the muscles are separated the instrument 
does not go sufficiently deep in the neck to touch the 
facial nerve. There is more danger of this accident while 
separating the structures attached to the anterior part 
of the tip. The facial nerve is very rarely wounded in 
this location but the ])()ssibility of this occurring is to be 
borne in mind. That the tip is thoroughly *' freed" may 
be ascertained by the fact that its apex can be felt by the 
finger passed beneath it. 

Posterior Incision. — The posterior incision may be 
made at this stage as advised by Whiting, or may be 
deferred until later when it is discovered that more 
room is needed. It is to be made on a level with the 
auditory meatus and extends from the margin of the pos- 
terior flap toward the occiput for from one-half to one 
inch, according to the room needed. The only objection 
to making it early is that in elevating these flaps the 
mastoid emissary vein is sometimes torn and leads to 
troublesome bleeding. The posterior flajrs are now 
elevated, but the retractor is not inserted until during 
the o])eration it is foimd necessary. 

Inspection of Cortex. — The surface of the bone is now 
inspected. If there is a subperiosteal abscess, the avenue 
of exit of the pus from the mastoid is to be found. This 
may be a cortical perforation on almost any part of the 
mastoid surface, in the zygomatic region or on the pos- 
terior canal wall through the premastoid lamina, or the 
pus may have dissected its way out through the Rivinian 
segment. When no subperiosteal abscess is present, the 
mastoid surface often presents a shaven beard appear- 
ance, being covered with little bleeding points usually 
indicating that an active process is going on within. 



MASTOID OPERATION 



223 



Removal of Cortex. — The next step is to remove the 
cortex and thus open the mastoid. In doing this a large- 
sized gouge is used and shavings of bone removed until 
the cells are encountered or pus wells up. If there is a 
perforation in the mastoid cortex, the removal of bone 
is begun from it, working in a direction downward and 
forward. It can readily be seen that the perforation may 
lie on the confines of either the sinus or dura, and if 
bone is removed upward or backward these structures 




Fig. 70. — Mastoid cells opened upon completion of the groove along 
the posterior border of the canal. 

may be endangered. This is to be avoided by adopting 
the plan advised above. If no cortical perforation is 
present, the best plan is to begin the removal of bone 
from the Dench triangle downward, keeping near the 
posterior wall and ending the cut in the cortex of the tip 
(Fig. 70). If -the mastoid is a pneumatic one, and pro- 
cesses in this type of bone are those usually requiring 
operation, the second or third shaving in this gutter 
will open the cells or permit the exit of pus, although at 



224 



MASTOIDITIS 



times the first shaving will do this, depending on the 
thickness of the cortex. Once the cells or the cavity of 
the mastoid is opened, one determines the topography 
of the individual mastoid upon which he is operating. 
He then proceeds to remove the remaining cortex insofar 
as possible without endangering the sinus or dura (Fig. 
71). In removing the cortex, as well as using the gouge 
in any other part of the mastoid operation, it should be 
directed parallel with the sinus or dura and should be 
well under control. That is, it should not point in the 




Fig. 71. — Cortex completely removed. 

direction of the sinus or dura so that should it go farther 
than intended upon being struck with the mallet, these 
structures would be in danger of being wounded. If, 
as the cortex is being removed, pus wells up in greater 
quantity than could be contained in the mastoid cavity, 
one may safely assume that there is either a perisinus or 
extradural abscess w^ith these structures exposed, and 
therefore exercise greater care not to wound them. It 
is always well after removal of the cortex, if an abscess 
cavity has been opened, to sponge it thoroughly and care- 



MASTOID OPERATION 225 

fully, and inspect its walls. One by this procedure fre- 
quently derives an early knowledge that the sinus is 
exposed, and thus is in a position to avoid wounding it. 

Removal of Tip. — It is often a good plan to remove the 
tip at this stage. For this purpose the gouge may be 
used, but ^the author prefers ^Nlathieu's rongeur. One 
blade of this instrument is forced beneath the tip, taking 
care to hug the bone closely, and the piece grasped 
removed. If any soft parts are taken they are to be cut 
off with the scissors at the rongeur jaws. If cut farther 
from the jaws, there is greater possibility of wounding 
the facial nerve. It usually takes several bites of the 
rongeur to thoroughly remove the tip. That this is done 
is shown by the exposure of the digastric muscle, the 
fibers of which run forward and slightly downward. 

Removal of Cells. — Frequently at this stage the inner 
table over the sinus or sinus plate, as it is called, can be 
made out. This is recognized by its color and contour. 
Its color is either white if the bone is thick, or of a slightly 
bluish color if thin and the sinus shows through. If 
it cannot be made out, the cells are removed with a curette 
until it is encountered, working upward and gradually 
and carefully backward from the lower part of the bone 
wound until it does come into view. In doing this 
work one good way of holding the curette is shown in 
Fig. 72. Grasped in this manner the instrument is 
under control; the wrist, being at rest on the parts around 
the wound, does not allow the point of the curette to slip 
and do damage. The thumb near the end of the instru- 
ment enables one to use great force safely. Another good 
method is to place the spoon of the instrument beneath 
any projecting edge of a cell wall and remove the parts 
in an outward direction by using the upper margin 
of the bone wound as a fulcrum. The side of the bowl 
being toward the sinus and the force exerted outward, 
this structure is safe. Some force may be used in an 
anterior direction toward the posterior canal wall. If, 
as the cells are being removed, working upward, the sinus 
15 



226 



MASTOIDITIS 



is accidentally exposed, or if there is a perisinus abscess, 
it is best to do the work around the antrum and in the 
other parts of the bone and come back to the region of 
the exposure at the end of the operation. The reason for 
this is that if the sinus is wounded it renders the rest 
of the operation more difficult, so it is advisable to post- 
pone any danger of this accident until the end of the 




Fig. 72. — One method of using the curette while removing mastoid cells. 



operation. If no sinus exposure occurs, the cells are 
removed from the sinus plate behind to the posterior 
wall of the canal in front. If in doing this, there is an 
overhanging cortex, it may be taken away with the 
rongeur or large-sized gouge. Considerable variation 
in the mode of removing cells is not only allowable, but 
also advisable. The operator should study each manipu- 
lation which his ingenuity suggests in order to determine 



MASTOID OPERATION 227 

that neither the sinus nor dura are endangered. Espe- 
cially if a small curette is used, no force should be exerted 
in the direction of these structures, as the bone between 
the instrument and them may be thinner or less firm 
than it was believed to be and the instrument may easily 
penetrate them, perhaps carrying in its bowl much infec- 
tious material. A large-sized curette may be used to 
remove rough projections from the inner table over the 
sinus and dura, but even with this instrument but little 
bone should be taken at a time and the force used must 
be gentle. 

The cells in the angle formed by the knee of the sinus 
and the inner table of the middle fossa are to be removed. 
They are sometimes very extensive in this location, and 
as they are taken away the inner table covering the dura 
above and the sinus below is mapped out. One must 
work carefully, as both of these structures are endangered. 

The cells forward are removed, working along the 
inner table of the middle fossa until the antrum is opened. 
The cells existing in the posterior root of the zygoma and 
above the external auditory meatus are to be removed. 
The best method of doing this is as follows: th^ small 
curette is inserted into the antrum with bowl directed 
outward; then by using the posterior margin of the bone 
wound as a fulcrum, the spoon is made to travel outward 
taking the cells, and at the same time the instrument is 
rotated so that the back of the bowl becomes more and 
more directed toward the inner table, thereby assuring 
the safety of the dura. This procedure forms a cortical 
overhang which may be taken away with the rongeur or 
small gouge. The curette should never be introduced 
into the additus and removed scraping in an inward and 
downward direction, as it may catch the short process 
of the incus which lies in this situation and thus remove 
the ossicle. 

Facial Nerve. — Sometimes the cells extend very deeply 
between the sinus plate and the posterior wall of the 
canal, and one feels that he is working in dangerous prox- 



228 MASTOIDITIS 

imity to the facial nerve while removing them. If these 
cells exist well forward and very deep, one should not 
curette their anterior walls; all posterior to them may 
with safety be removed until the internal table of the 
posterior fossa is encountered. In excavating these 
cells, the facial nerve is located by calculating its course 
from the horizontal semicircular canal. If this cannot 
be seen, as is often the case, it is to be remembered that 
it lies in the floor of the additus, the location of which 
may be readily determined witli a bent probe. The nerve 
should lie internal to a line drawn downward from this 
canal parallel with the median line of the body. The 
prominence of the posterior semicircular canal is also 
about on this line and situated more posteriorly than 
the nerve. 

Extradural Abscesses. — If an extradural abscess is 
found, the method of dealing witli it depends upon the 
character of its dural wall. If this structure is covered 
with fine granulations, they are not to be molested. If, 
however, these granulations are very thick, as they are 
at times found to be in neglected cases, they may be 
removed. They sometimes spring from the sinus, nearly 
filling the mastoid cavity and may be mistaken for this 
structure until carefully examined. One may remove 
them if care is taken not to wound the sinus. In either 
event, the inner table is to be removed until healthy dura 
is encountered. This may be recognized by its color and 
general appearance. In removing this inner table the 
MacKernon rongeur forceps will be found useful. One 
jaw is inserted between it and the dura or sinus wall, 
hugging the bone, and before closing slightly withdrawn. 
This prevents nipping the dura which may be folded 
between the jaw and the bone. Some operators prefer 
the curette. If it is used, the same care should be taken 
to avoid nipping the dura. When the operation is com- 
pleted, the cavity usually resembles that shown in Fig. 
73, with the exception that the sinus should not be 
exposed. 



MASTOID OPERATION 



229 



Injury to the Sinus. — If at any time during the operation 
the sinus is wounded, the hemorrhage may be temporarily 
arrested by the operator placing his finger over the wound, 
then as he removes the finger iodoformized gauze is packed 
firmly against the sinus in the region of the wound. It 
is well, while working in the neighborhood of an exposed 




Fig. 73. — Operation for sinus thrombosis. The gauze rolls are in 
position and the sinus incised. The figure also shows the completed 
mastoid operation. 



sinus, to have the gauze ready and the assistant on the 
alert, so that should bleeding occur the gauze may be 
rapidly placed in position. In some instances the gauze 
may be held by pressure and the operation completed, 
or if the operation is practically completed, the wound 
may be packed and the dressing applied. This method 



230 MASTOIDITIS 

of treating a wounded sinus may not lead to its oblitera- 
tion. It may be possible after the hemorrhage is con- 
trolled to insert the gauze rolls as described under Sinus 
Thrombosis. If these are inserted, it leads to the oblitera- 
tion of the sinus. They are usually, however, more con- 
venient in the subsequent dressing of the wound. The 
subsequent course of a patient with a wounded sinus 
depends largely upon whether or not infection is intro- 
duced into this vessel. The author has wounded the 
sinus on three occasions without noticeable symptoms 
following, but he personally knows of other instances 
in which the accident has been followed by grave conse- 
quences, even death in some cases. 

Injury to the Dura. — If the dura is wounded, unless the 
opening is already sufficiently large, which is seldom the 
case, the wound is to be enlarged by a linear incision of 
the dura passing through the puncture and iodoformized 
gauze packed in contact with the brain. This ])r()vides 
for drainage and aids in preventing meningitis. 

Dressing. — The operation being completed, the pos- 
terior incision, if one was made, is first sutured; then 
the upper end of the original curvilinear incision is closed 
sufficiently to cover the surface of the squama which has 
been laid bare. Further closure is at the option of the 
operator, but the opening is usually left about one inch 
in length. Michel's clamps are excellent for bringing 
the flaps together. The wound is packed with iodofor- 
mized gauze, a sterile gauze strip placed in the canal, 
a circle of fluffed gauze is placed over the ear so that the 
auricle will not be cramped. Then a fluffed gauze pad is 
applied over all and upon this, absorbent cotton, and the 
whole retained by a bandage. It is important that the 
bandage should cover the cotton and draw firmly against 
the cheek and neck, especially in children who are apt, 
if the bandage is loose in this location, to insert their 
fingers and cause infection of the wound. 

Mastoid Operation in Infants. — The mastoid operation 
in infants varies somewhat on account of anatomical 



MASTOID OPERATION 231 

conditions. As the facial nerve is superficial, the incision 
is started more posteriorly below. As there is no tip, this 
structure cannot be removed. An attempt to remove 
what seems to be the tip only results in endangering the 
facial nerve. There is no osseous canal at birth, the auricle 
lying upon the squama. For this reason after elevating 
the flaps one often finds the exposure much higher than 
he supposed it would be, while making the incision. As 
there is no osseous meatus, one uses as a guide to the 
antrum either the posterior horn of the tympanic ring or 
the attachment of the canal to the ring, the antrum being 
located by lines similar to those in the Dench triangle. 
The antrum is much more superficial than in adults. 
An accident which may happen is that, when elevating 
the flaps the canal ma}' be torn from the tympanic ring. 
If this is done, one might mistake the red thickened drum 
membrane for a cortical perforation. Merely to bear this 
possibility in mind is sufficient to avoid the mistake. 

As the soft parts are often thickened in these little 
patients, it is frequently quite difficult to obtain a good 
exposure of the field and make out the landmarks. This 
should be done deliberately and with no haste, as the 
bone work is soon done once it is properly begun. In 
infants at times the squama is very soft, and it is possible 
to cut it with the knife when making the original incision, 
so one should not expect the knife to meet with the same 
resistance as in adult bones. Care should also be taken 
while separating the periosteum from these soft bones, 
as the elevator may be forced through the bone and this 
structure be separated from the dura or the latter 
wounded. If the child is older, there is a slight shelving 
near the tympanic ring, marking the beginning of the 
development of the osseous meatus and the antrum may 
be located as in adult cases. Very little work with the 
gouge is necessary in young children. A small shaving of 
bone is removed over the antrum, but the groove should 
not be made as in adults. After a small piece of bone is 
taken from the cortex, the rest of the operation may be 



232 MASTOIDITIS 

finished chiefly with the curette. The zygomatic cells 
are to be removed, as they are frequently developed out 
of proportion to the other cells. 

Secondary Operation. — It occasionally becomes neces- 
sary to perform a mastoid operation upon a patient who 
has previously had this operation done. While in the 
main the procedure is the same as in the primary cases, 
one point demands attention. It may be that the sur- 
geon knows how much of the sinus or dura was exposed 
at the previous operation. If he is not so fortunate, great 
care must be exercised in making the incision and exposing 
the field. The knife cannot be pressed down until bone 
is encountered, as it may open the sinus or dura. Usually 
one may cut to the bone above the auricle and also near 
the tip. Working from these points, with careful dissec- 
tion with the scalpel aided ])erha])s with the curette, the 
surgeon exposes the field and locates the landmarks. Then . 
the granulations, necrotic bone, etc., are removed upon the 
same principles as in the primary mastoid o])eration. 

After-treatment. — The outside dressing is usually 
changed on the day following the operation. The clamps 
are removed in two days and the packing is changed in 
four days. After this, the wound may be dressed daily 
for a week or so, after which it may be allowed to go two 
days if the secretion is scanty. At each dressing after 
the first week or ten days, the wound is wiped with the 
cotton applicator, saturated with one-half strength perox- 
ide of hydrogen (10 volume solution). 

Temperature. — The temperature usually has a post- 
operative rise on the following day, not as a rule higher 
than around 102° F. If the temperature stays up or rises 
two or three days after the operation, the packing should 
be changed to ascertain, if possible, the cause. J'his 
may be infection of the wound; if not, further search 
should be made. (See Sinus Thrombosis and Meningitis.) 
A thorough physical examination is made of the patient, 
as the cause of fever may not be directly connected with 
the mastoid infection. 



MASTOID OPERATION 233 

Granulations. — If the granulations become too exuberant, 
tincture of iodin may be applied after the parts are 
cleansed with the peroxide solution. As a rule these 
granulating wounds should be hghtly packed, taking care 
that drainage is good. If the granulations are interfering 
with drainage or are large and flabby along the margin 
of the wound, they should be removed with the curette or 
scissors and their bases cauterized with a fused bead 
of nitrate of silver. The secret of success in mastoid 
dressings is cleanliness and the ability to determine when 
granulations are doing their work properly and need 
encouragement, and when they are interfering with 
drainage or causing infection and demand removal. As 
the discharge decreases and the cavity becomes smaller, 
a patch may be worn in place of the bandage, or the 
small dressing which is now required may be held in place 
by painting with collodion. If all goes well, the wound 
heals in about six weeks. Occasionally the time is a week 
or so shorter, but it is much more frequently longer. 

Delayed Healing. — At times it fails to heal, a sinus 
persisting that will not close. These sinuses usually 
lead into the antrum and tympanum. A frequent cause 
is the continuance of suppuration in the middle ear. 
One is not inclined, while performing the mastoid opera- 
tion, to disturb the structures in the vault of the tym- 
panum. A necrotic ossicle, local caries of the tympanic 
walls, granulations or infected mucous membrane in the 
tympanic cavity, may keep the discharge active and 
prevent the posterior sinus from closing. At times the 
middle-ear process may be prevented from healing by 
adenoids and healing takes place after their removal. 
The sinus will at times heal if swabbed w^ith iodin and not 
packed, at others a strand of gauze carried well into the 
antrum seems to hasten its closure. If it persists in spite 
of all treatment, a secondary mastoid or a radical opera- 
tion will be necessary. It may be difficult to decide 
which to do in any individual patient. A decision is 
usually reached by the condition of the middle ear, the 



234 MASTOIDITIS 

chronicity of the process and often the findings at the 
secondary operation. 

Prognosis. — The prognosis of the simple mastoid must 
be considered good. If the patient has compHcations 
before operation, the outlook naturally is less favorable; 
and these will at times occur after operation and produce 
death. The mortality is probably not over 2 per cent. 
The author has performed about 300 simple mastoid 
operations and so far as known but two patients have 
died. The death in each instance occurred after the 
patient passed from observation, and the cause is not 
known. 

Blood-clot Treatment of the Wound. — A method of deal- 
ing with the mastoid cavity that has a few adherents is 
the blood-clot method. It consists in completely closing 
the incision with sutures or clamps and allowing the 
cavity to fill with blood. This clots, and at times becomes 
organized, resulting in greatly shortening the time 
required for healing and also in the production of a very 
slight scar. It more often breaks down and after the 
wound becomes clean healing takes place as in the ordinary 
method. It is without doubt slightly more dangerous 
and has not come into general use. 



CHAPTER VIII. 
SINUS THROMBOSIS (THRO:\IBOPHLEBITIS). 

The anatomy of the dural sinuses may be learned from 
the study of the text-books on Anatomy. Otologists 
are mainly concerned with the lateral sinus, jugular bulb 
and vein, more rarely with the superior and inferior 
petrosal, and the cavernous sinus. When ^'the sinus'' is 
mentioned without qualification the lateral sinus is always 
meant. 

Definition. — The term ''sinus thrombosis" is applied to 
an infective process involving the dural sinuses which 
results in the formation of infective thrombi. This defini- 
tion does not cover marantic thrombi nor those which 
sometimes form in the mastoid region without apparent 
infection, and either become organized, obliterating the 
sinus, or float into the circulation, causing sudden death 
from pulmonary embolism. Day^ has recently called 
attention to this type of sinus thrombosis and reported 
six cases in which the clot was found organized or in 
process of becoming so. In some the lateral sinus consisted 
of a hard cord which upon incision proved to be firmly 
organized tissue, w^hile in others the process had not gone 
so far. These patients did not present symptoms which 
could be attributed to sinus thrombosis, nor did they 
show a bacteremia, the diagnosis being made at the 
operation upon the mastoid. 

Pathology and Causation. — The process is a phlebitis 
affecting the sinus wall and extending to the intima, thus 
producing a clot of varying size, or the thrombus may 
result from injury to the vessel or the infection may extend 
through the veins connecting the sinus with the original 

1 Transactions of the American Otological Society, vol. xiii, part 3. 



236 SINUS THROMBOSIS 

process. It is well to bear in mind the fact that the 
inflammation of the internal layer of the sinus wall is an 
essential part of the process, although this in itself is not 
the cause of the symptoms. An injury to this coat of the 
vessel will result in a clot being formed, but unless the 
reparative process is complicated by the invasion of 
bacteria, the clot will become organized and the wound 
thus healed without the formation of an infective thrombus 
or the presence of symptoms. Therefore, in an injury 
to the sinus a great deal depends upon the nature of the 
field in determining whether the process which results 
will be one of repair or of an infective nature. Penetrating 
wounds in a septic field are especially diastrous, while 
such an injury in a clean field may heal without compli- 
cations. A non-penetrating wound in a septic field may 
heal kindly or infection may occur. When such an injury 
heals without symptoms, it justifies the assumption that 
the resulting hemorrhage washed the infective material 
away before infection could take place. Nevertheless, 
a wound of the sinus is an accident of serious nature, and 
may be the starting-point of a sinus phlebitis of severe 
type. In a perisinous abscess one usually finds that 
granulations have formed protecting the sinus. At times, 
however, before this takes place the inflammation extends 
to the intima, thus producing a clot of greater or less size. 
The lateral sinus is usually the one involved, but the 
superior or inferior petrosal may be affected or the infec- 
tion may extend to the jugular bulb through the tympanic 
floor or the condyloid veins. The process usually extends 
from the lateral sinus into the jugular vein, but it may 
also extend backward toward the torcular, even passing 
this point and involving the sinus on the opposite side. 
Rarely, by extension through the inferior petrosal, caver-' 
nous sinus thrombosis takes place. 

If a mastoid operation has been done and the sinus 
exposed, its examination may show no indication of its 
involvement, although phlebitis with a mural clot may be 
present; but if the sinus is totally occluded by a thrombus, 



SYMPTOMS 237 

it is apt to be more firm on pressure and not so resilient, 
and if it has existed some time there may be discoloration 
of the sinus wall and surrounding dura. At times the 
thrombus may have broken down and an abscess formed, 
which may have ruptiu^ed through the sinus wall. Such 
an abscess might not cause general infection if it was 
thoroughly walled off by organized clot, but by rupturing 
internally could readily produce meningitis or cerebellar 
abscess. 

Symptoms. — When a clot which has formed in the sinus 
breaks down through growth of bacteria and pieces 
float into the general circulation, symptoms are procluced. 
The same result follows if a very small clot clinging to the 
sinus wall floats away. There is a sharp rise of tempera- 
ture, usually preceded by a chill or chilly sensations. The 
rise reaches to between 103° and 106° F., or even higher 
in exceptional instances. It falls in an hour or more to 
normal if there are no complications, and may be followed 
by sweating. This typical temperature curve is no doubt 
caused by the reaction of the patient to ^he introduction 
into the circulation of septic material as above stated. 
The attack of fever and so forth may be repeated in a few 
hours or on the following day, or even later, according to 
the activity of the process. Between the attacks in the 
early stages of the disease the patient feels quite well 
and does not seem sifck. As the disease progresses and 
metastases develop, the -temperature does not fall to 
normal between the rises and the patient seems sick all 
of the time. Exceptionally, the temperature does not fall 
to normal even in the beginning of the disease. This will 
usually be due to the fact that a certain amount of the 
fever is due to other processes than the sinus thrombosis. 
Then the temperature is more or less remittent in type. 

The lymphatics along the jugular vein may be enlarged 
and tender from the process having extended into the 
vein. If the disease is neglected, they maV break down 
and form abscesses. Changes in the eye-grounds fre- 
quently occur, either before or after operation. They 



238 SINUS THROMBOSIS 

are evidently due to increased intracranial pressure and 
are more apt to be present if the vein involved is a large 
one and the interference with the return flow from the 
brain consequently greater. Greissenger's symptom is 
sometimes present. This consists of an edema and swell- 
ing, over the mastoid posteriorly and extending into 
the neck, which is caused by occlusion of the mastoid 
emissary vein. Various symptoms of uncommon occur- 
rence have been attributed to jugular bulb involvement 
affecting the pneumogastric, spinal accessory, or glosso- 
pharyngeal nerves as they lie adjacent to the bulb in the 
foramen lacerum posterius. As the disease progresses 
without treatment, general sepsis usually occurs with the 
formation, in various parts of the body, of metastatic 
abscesses. 

After the lapse of a varying length of time after the 
first rise of temperature in sinus thrombosis, if a culture 
of the blood taken from the general circulation is made, 
colonies of bacteria will usually grow within twenty-four 
to thirty-six hours. The bacteria which are found to be 
growing are usually of the same variety as those found in 
the aural pus and after jugular resection in the vein also. 
While bacteremia may doubtless be present in other 
conditions, the fact that it occurs in a patient suspected 
of having sinus thrombosis becomes of great value in the 
study of the disease. 

Diagnosis. — In forming an early diagnosis, tw() j)()ints 
are of supreme importance, namely, the temperature curve 
and the bacteremia. In typical cases the temperature 
curve is very much like that of intermittent fever, although 
the individual attacks of fever do not, as a rule, follow 
with such regularity as do the paroxysms of malaria. 
In the latter there is the chill, the rapid rise of temperature 
with the rapid fall, followed by sweating. These may 
all occur in sinus thrombosis, although the chill and 
sweating may be less marked. Fortunately, the examina- 
tion of the blood excludes malaria; for if the plasmodia 
of this disease existed in sufficient numbers to produce 



PROGNOSIS 239 

such a paroxysm, examination of the blood would readily 
determine their presence. If the temperature curve is 
characteristic and malaria is excluded, the surgeon is 
justified in operating after the second rise, provided that a 
thorough examination of the patient fails to account for 
the temperature in any other way. If bacteremia is 
present before the second rise, the surgeon should operate. 
It may at times be extremely difficult to be certain that a 
single rise of temperature, no matter how characteristic 
it may apparently be, is due to sinus thrombosis. So one 
would be inclined to wait for the result of the blood culture 
or a second rise before operating, unless from the operative 
findings in the mastoidectomy (usually injury to sinus) 
he had reason to expect that involvement of the sinus was 
especially probable to take place. In atypical cases where 
the other causes for the temperature are exhausted, one 
might be justified in exploring the sinus and removing the 
jugular vein, but if the blood culture was positive it would 
be imperative for him to do so. Occasionally the patient 
either comes under observation when metastases have 
developed or, what is still rarer, develop them in spite 
of the surgeon's vigilance. These secondary infections 
indicate with great certainty that sinus thromobosis is 
present, provided, of course, that no other cause is 
apparent or discoverable. 

Prognosis. — ^The prognosis of sinus thrombosis is always 
grave. ]Many patients recover after operation, while 
from time to time instances of a spontaneous cure are 
reported. If the thrombus is well walled off by organized 
clot, it may break down and the abscess thus formed 
rupture, through the external w^all of the sinus into the 
mastoid cavity. It is possible for such a process to resolve 
without further operation than a mastoidectomy. Sinus 
thrombosis is also a not infrequent cause of meningitis 
and brain abscess, and this must be taken into account in 
estimating the probable outcome. Probably a conserva- 
tive estimate of the mortality is that from 15 to 25 per 
cent, of the patients die. 



240 SINUS THROMBOSIS 

Treatment. — A great deal may be done to prevent 
sinus thrombosis by a careful operative technic. Some 
inflammations of the sinus wall which result in the pro- 
duction of infective thrombi are caused by wounds which 
the surgeon knows that he has made; how many are 
caused by injuries which do not result in bleeding it is 
naturally difficult to say. It is, however, very probable 
that this occurs much more often than is supposed. 
A little spicule of bone piercing the sinus wall, or rough 
handling of the sinus, may result in the introduction of 
bacteria to a sufficient de])th in its wall to ])roduce an 
inflammation which extends to the intima. The number 
of patients who develop sinus thrombosis varies greatly 
in the experience of different surgeons and may to a 
certain extent at least, without injustice, be attributed 
to their lack of taking proper care of the sinus (hu'ing 
operation. If tlie sinus is involved l)efore operation, 
these remarks naturally do not apply; nor is it intended 
to convey the impression that a sinus thrombosis develop- 
ing after the mastoid operation is necessarily due to 
improper technic, but that it may be, cannot be ques- 
tioned. The proper treatment for the disease when 
developed is operation. The surgeon cannot take the 
responsibility of any exi)ectant plan of treatment. He 
owes it to his patient to insist upon operation, and that 
at the earliest possible moment after the diagnosis has 
been established. 

SINUS OPERATION. 

Sinus Exposure. — The sinus is exposed from the knee to 
as near the bulb as possible. If it has not been previously 
exposed, the best instrument to begin the work is a large 
gouge. With this one takes successive shavings from the 
sinus plate until the sinus is bare, then with a curette 
or ]\IacKernon's rongeur forceps the removal of the sinus 
plate is continued. 

Incision of Sinus. — ^When sufficient exposure of the sinus 
is effected, small pledgets of rolled iodoformized gauze 



SINUS OPERATION 241 

are inserted between the inner table and sinus wall (Fig. 
73) at either end of the exposed vessel. Unless there is a 
firm clot, they are inserted with sufficient firmness to 
bring the sinus walls into contact with each other, that 
is, collapse the vessel. The external sinus wall is now 
incised longitudinally, as shown in the figure. In making 
this incision, care must be taken not to injure the internal 
wall, as this opens the subdural space and may lead to 
infection of the brain or meninges. The outer wall may 
be picked up with a mouse-toothed forceps, nicked, and 
the incision completed upon a grooved director, or with 
probe-pointed scissors. In this way injury to the internal 
sinus wall will be less probable. 

Removal of the Clot. — If there is a clot in the sinus, it is 
turned out and the walls inspected. The lower gauze roll 
is now removed and if hemorrhage is free immediately 
replaced. If bleeding does not occur freely from this lower 
end, a dull ring curette may be introduced with the 
object of dislodging the clot which must be done if possible, 
especially if it extends into the inferior petrosal sinus. 
Under no circumstances is a sharp instrument to be used, 
as injury to the intima may be produced, resulting in 
phlebitis and extension of the process. If this maneuver 
succeeds in producing free bleeding from below, the gauze 
roll is replaced and the upper end dealt with in the same 
manner. If bleeding does not take place from the upper 
end after the pledget has been removed and the dull ring 
curette used, it indicates that the clot extends backward 
toward the torcular. This clot must be removed, as if 
it is allowed to extend the sinus on the opposite side may 
become involved. To accomplish this bone is removed 
over the line of the sinus, which has been ascertained by the 
direction of the dull curette when attempting to remove 
the clot. The outer wall of the exposed sinus is incised 
and the bone removal continued until free bleeding is 
obtained, even if it is necessary to extend the operation 
to the median line to do so. 
16 



242 SINUS THROMBOSIS 

Jugular Resection. — Indications. — If upon making the 
initial opening of the sinus a firm clot is found, and after 
its removal free bleeding is obtained from below, the 
jugular operation may be postponed if the patient seems 
weak or there is any other good reason for doing so. This 
is not advised, but one may justify oneself for doing so. 
If, however, no clot is discovered, or only a small one, the 
jugular resection must be done at once. If sufficient 
reasons existed to justify exj)loration of the sinus, nothing 
will be accomplished under these circumstances unless the 
jugular is resected, as there is in all probability a mural 
clot with phlebitis, and the process exten<ling as it may 
beyond the limits of the exposed sinus is in no way 
influenced by the sinus operation. 

There is no good reason why the jugular should not be 
resected before the sinus is exi)l()red. The instruments 
and hands of the surgeon and assistants are sterile and the 
necessity of resterilization before ])erf()rming the jugular 
operation is avoided. 

Operation. — The neck is prepared as for any surgical 
operation. The shoulders of the patient are ])laced 
upon a sand-bag to allow the head to fall backward 
and produce a prominence of the sternomastoid muscle. 
The incision is made along the anterior border of this 
muscle, reaching from slightly above the clavicle to near 
the angle of the mandible, and extends through the skin, 
superficial fascia and platysma myoides, and usually 
reveals the fibers of the sternomastoid muscle. If it does 
not, this muscle should be sought by pushing back the 
posterior margin of the wound with the handle of the 
scalpel. Having located the anterior border of this 
muscle, it is held back with a blunt retractor. An anterior 
retractor is not advised, as the relation of the parts is often 
obscured by its use. Throughout the rest of the operation 
blunt dissection is used. By retracting the sternomastoid 
muscle, the sheath of the vessels is exposed. The vein 
lies external to the common carotid artery (Fig. 74) and 
between the two, but on a deeper level, the pneumogastric 



JUGULAR OPERATION 



243 



nerve. The nerve is not shown in the cut as it does not 
come into view until a later stage in the operation. At 
the lower part of the incision passing over the sheath, 
and therefore superficial to the vessels, is the anterior 




Fig. 74. — The vein and artery exposed in the operation for jugular 
excision. The pneumogastric nerve does not show, as it is covered by 
the artery and the vein. 

belly of the h omohyoid muscle. Lying in the sheath 
superficial to the vessels is the decendens hypoglossi. 
This may at times be seen but no attempt to preserve 
it is made. If from the appearance of the vein or any 
other reason a low resection is determined upon, the 



244 SINUS THROMBOSIS 

homohyoid muscle may be divided on a grooved director. 
The sheath of the vessels is merely a thin layer of 
connective tissue and requires no division. If one con- 
ceives this sheath as tissue which must be passed through 
before coming in contact with the vein, he will often 
enter the vein in trying to do this. Disregarding the 
sheath, the vein is separated (with the handle of the 
scalpel) from the other structures with which it is asso- 
ciated. The artery is not disturbed as its location may 
readily be determined by its pulsation. Care is taken 
not to wound the vein. If this accident occurs, it should 
be caught in the forceps at the site of the bleeding. It is 
separated below and a double ligature thrown around it. 
Before tying these ligatures, the surgeon makes sure that 
the pneumogastric nerve is not included within them by 
drawing the vein outward and locating the nerve in 
relation with the artery in the bed from which the vein 
has been separated. Under no circumstances is the nerve 
to be handled or picked up with the forceps. The liga- 
tures are now tied and the vein divided between them, 
and the upper end caught in a forceps to prevent hemor- 
rhage in the subsequent steps of the operation should the 
ligature slip. The vein is now separated, working upward, 
and its anterior branches tied and incised between two 
ligatures. There may be three of these, corresponding 
to the thyroid, lingual and facial branches of the carotid, 
but the more common arrangement is for these branches 
to be represented by one large anterior trunk; at times, 
there are two. There are none posteriorly unless anoma- 
lous ones. The vein is separated to a little above this 
anterior branch or branches, and cut between two ligatures. 
In working in the upper angle of the wound, care should be 
taken not to injure the spinal accessory nerve. This may 
not be encountered if it lies behind the vein in its course 
to the sternomastoid muscle; but it may pass in front 
of the vein when it is to a slight degree endangered. This 
removes the vein and the pneumogastric nerve is more or 
less plainly visible (see Fig. 75). A strip of gauze may be 



JUGULAR OPERATION 



245 



inserted in either angle of the wound for drainage, the 
two nearly meeting in the centre, and the skin incision 
closed with clamps and a sterile dressing applied. 

After-treatment. — The clamps are removed in two or 
three days and the gauze drains shortened as fast as 




Fig. 75. — The jugular vein is removed thus allowing the pneumo- 
gastric nerve to come into view. 

permitted by the necessity for drainage. The mastoid 
wound is dressed as in the ordinary mastoid operation 
with the exception of the gauze rolls which control the 
bleeding. The upper one very seldom causes any diffi- 
culty and may be removed in about four days without 
the occurrence of hemorrhage; however, should bleeding 



246 STNUS THROMBOSIS 

occur, it must be reapplied and allowed to remain for a 
few days more. If there are no contraindications, the 
lower one may be left for five days. One must be prepared 
for bleeding when changing this and immediately insert 
a fresh one. Usually there is no hemorrhage at the second 
dressing two or three days later. Once the bleeding does 
not take place when the gauze rolls are removed, the wound 
is taken care of as after the mastoid operation. In the 
after-treatment of these patients, when after all that has 
been done, some sepsis remains, benefit may at times be 
obtained from the administration of an autogenous 
vaccine or the His leukocyte extract. 

If the temperature does not fall after the operation, 
within a few days search should be made for a focus of 
infection which may have been left. This may be in the 
sinus toward the torcular, in the jugular bulb and inferior 
petrosal sinus, or rarely in the lower end of the vein which 
at the operation was not removed sufficiently low in the 
neck, lender these circumstances, the sinus must be 
explored posteriorly even to the median line if necessary 
or more of the lower end of the jugular resected. 

Gutter Operation, — If the bulb appears to be involved, 
it may be opened by the gutter operation. This operation 
is performed by uniting the upper end of the jugular 
incision with the lower end of the mastoid incision. In 
doing this care should be taken not to wound the facial 
and deeper in the wound the hypoglossal which emerges 
just anterior to the vein. The bone is removed over the 
sinus, working downward until the external surface of the 
bulb continuous with the vein is reached. This removes 
the outer margin of the jugular foramen. The outer wall 
of the bulb may be incised and the clot cleared out. 
Great care should be taken not to wound the structures 
adjacent to the inner wall of the sinus or bulb in the 
jugular foramen, as in this location the ninth, tenth and 
eleventh cranial nerves are found. Usually removal of 
the clot from the bulb will result in free bleeding from the 
inferior petrosal sinus; if it does not no attempt should 



BLEEDING SINUS 247 

be made to secure this result by introducing a curette. 
The gutter operation is a formidable procedure and 
requires for its performance an intimate knowledge of 
the anatomical conditions. Fortunately it is but rarely 
required. 

BLEEDING SINUS. 

Pathology. — Occasionally after a mastoid operation in 
which the sinus has been exposed, bleeding occurs dm^ing 
the healing process. There is great variation in the thick- 
ness of the outer wall of the sinus in different subjects. In 
some it is so thin that the blue color of the venous blood 
shows through very plainly; in others, so thick that the 
sinus wall does not differ in color from the dura in other 
situations. It is in these thin sinuses that hemorrhage at 
times occurs. The wall does not appear to be thick 
enough to throw out granulations and take part in the 
healing process, as does the ordinary sinus wall. The 
surgeon may have noticed at the time of operation that the 
sinus appeared thin. The gauze was packed around the 
sinus as in ordinary dressings. During the healing process 
this thin wall, softened by the effort to throw out granula- 
tions, becomes adherent to the gauze, and when this is 
removed at the first or some subsequent dressing, there 
is a gush of blood, which coming so unexpectedly is truly 
alarming. 

Cases. — The author recently treated a patient who 
suffered from this condition. A girl, aged ten years, 
entered Dr. Dench's service at St. Luke's Hospital. 
Operation revealed a small perisinus abscess. The sinus 
wall was very thin. On the second dressing, five days 
after the operation as the house surgeon removed the 
packing, there was profuse bleeding which he immediately 
arrested by packing the wound with gauze. Every time 
the gauze over the sinus was removed during the ensuing 
three weeks profuse hemorrhage occurred. A small piece 
was therefore left at the location of the hemorrhage and 
changed about every six days, while the rest of the wound 



248 SINUS THROMBOSIS 

was dressed daily. The patient had one rise of tempera- 
ture (104.5° F.) on the day following the first bleeding, 
but as the blood culture was negative and no further rises 
occurred, the jugular w^as not resected. The recovery was 
complete. Two others have come under the author's 
observation, although not his personal patients. In one 
the history is practically the same as given above. In the 
other, the temperature remained of a somewhat remittent 
type, around 102° and 103° F., but as the blood culture 
remained negative, the jugular was not resected until a 
mestastasis developed, when this operation was done and 
a cure resulted. 

These patients are in a different class from those in 
whom bleeding occurs at the time of the operation, for 
one is then expecting hemorrhage at subsequent dressings 
and is prepared for it. 

Treatment. — The treatment is outlined in the descrip- 
tion of the above cases. If the vein is not too friable nor 
the bleeding very profuse, it is best to insert the gauze rolls 
as in sinus thrombosis operations. These can be left for 
about six days if the temperature remains down and the 
rest of the wound dressed daily. If this cannot be done, 
one must be satisfied with a piece of gauze, as small as 
possible, over the sinus wound. This to be left for from 
four to six days, while the remainder of the packing is 
removed and the wound dressed as required daily or every 
second day. 



CHAPTER IX. 

OTITIS MEDIA PURULEXTA CHRONICA 
(0. M. P. C). 

Chronic suppuration of the middle ear is a common 
disease and on account of the serious nature of its com- 
phcations one of the most important also. 

Etiology. — It usually follows and is a result of the acute 
form of suppuration. It is customary to consider the 
process chronic after it has existed three months. This 
is an arbitrary division but it answers very well. Some 
processes seem chronic from the outset, that is, develop 
without reactionary symptoms. Since chronic suppu- 
ration usually is^ a result of the acute form, the causes 
given for O. M. P. A. are operative in O. M. P. C. also. 
Lack of resistance, the serious nature of the lesions arising 
from the acute process, continuance of the nasopharyngeal 
lesion causing the acute disease (especially adenoids) are 
some of the influences producing chronicity. INIiddle-ear 
suppuration occurring in scarlatina, diphtheria, typhoid 
fever, and tuberculosis show a special tendency to become 
chronic. Chronic suppuration more often follows the 
acute form occurring in childhood, less often in adults. 

Pathology. — The changes in the mucous membrane are 
as follows: Thickening, infiltration with round cells, 
development of new connective tissue forming adhesions 
or bands; the epithelium may lose its ciliated character. 
Granulations and polypi may develop. Necrosis of the 
ossicles or walls of the tympanum and antrum may occur. 

Cholesteatoma. — Aural pus usually contains epithelial 
cells in varying numbers. When they become of the 
squamous variety and come from the tympanum and 



250 OTITIS MEDIA PURULENT A CHRONICA 

antrum, and their free discharge is interfered with, or 
the}^ are formed in excessive numbers, they accumulate 
in putty-Uke masses called cholesteatoma from the fact 
that these masses contain cholesterin crystals. The 
accumulations consist of epithelial debris or the cells 
may be arranged in the form of nests of greater or less 
consistency. The dermatization of the mucous membrane 
is usually brought about by the extension of the epithe- 
lium through a perforation; or it may in rare instances 
occur as a primary process, the ciliated epithelium becom- 
ing so changed that desquamation with accumulation of 
the scales takes place. As one often observes the inner 
wall of the tympanum dermatized without the process 
extending to the vault and antrum, it would seem that 
some change of the epithelium in the external auditory 
canal is necessary, or at least conduces to the formation 
of cholesteatoma. As the accumulation increases, and 
is unable to escape, pressure with erosion of the bone 
takes place. The entire mastoid cavity may become 
absorbed so that only the cortex remains, and even this 
may be perforated by the process. Or rupture through 
the inner table may occur and the masses accumulate 
between this structure and the dura which they press 
back upon the brain. The process may cause erosion 
of the posterior canal wall and the accumulation may 
escape through the meatus, and a cure may thus result. 
One not infrequently sees patients in whom this has 
taken place, the resulting cavity resembling to a certain- 
degree that left after the radical operation. The choles- 
teatomatous mass may burrow beneath the skin of the 
anterior canal wall, eroding the bone and involving the 
temporomaxillary articulation. Nor is the ivory-like 
bone of the labyrinthine capsule free from the encroach- 
ment of these masses, as they not infrequently erode the 
horizontal semicircular canal or more rarely other parts 
of the labyrinth. 

Symptoms. — There is regularly a purulent discharge 
in chronic suppuration of the middle ear, but there are 



SYMPTOMS 251 

great variations in its amount and character. In some 
patients it is free, appearing continuously at the outer 
end of the meatus; in others, being so scanty that it 
dries, either forming a crust on the walls of the canal or 
a plug completely occluding its lumen. Some patients 
may be free from discharge for varying periods, generally 
short ones, the disease being in a latent state, but by no 
means cured. At times it is thin and watery, at others, 
creamy and frankly purulent. It may possess odor or 
be free from it. Odor is due to the growth of the germs 
of putrefaction and is usually present in pus coming 
from cholesteatomatous processes or when bone necrosis 
is present. The impression that processes which cause 
foul discharge are more serious is usually justifiable, 
although not always correct. The pus may be more or 
less bloody in character when polypi or granulations are 
present. 

There is regularly more or less impairment of hearing 
which tests show to be due to disease of the sound-con- 
ducting mechanism. If the lab^Tinth is involved second- 
arily the characteristic tests of perceptive mechanism 
lesion will be present. At times patients come on account 
of their deafness, the discharge being so scanty that it 
has not annoyed them or at times even been noticed. 
The deafness is caused by lack of motility of the con- 
ducting mechanism, or to presence of secretion covering 
the labyrinthine fenestrae. In a few patients who had pro- 
found impairment of hearing associated with chronic 
suppuration ^Nlanasse found, postmortem, in their tem- 
poral bones the changes characteristic of otosclerosis, 

Tinnitus is often an annoying symptom and at times 
severe. As a rule, however, these patients do not com- 
plain of it as much as those suffering from chronic non- 
suppurative processes. Patients with chronic suppura- 
tion of the middle ear are apt to be below par physically. 
They may have the disease on account of their poor 
resistance or their physical inferiority may be due to the 
long-continuing suppuration. There can be no doubt 



252 OTITIS MEDIA PURULENTA CHRONICA 

but that this disease affords a focus of infection, the 
results arising from which are as yet scarcely known or 
appreciated. Children frequently show phenomenal im- 
provement after being cured of the middle-ear process, 
their backward development being fairly attributable to 
some deleterious influence arising from the disease. 

Facial paralysis occurs at times. It is due to necrosis 
of the bone containing the nerve, to neuritis or perineuritis 
caused by infection, usually through a dehiscence in the 
Fallopian canal wall, or to cholesteatomatous erosion 
and pressure. 

Loss of taste on the anterior two-thirds of the tongue 
on the involved side is present in nearly 50 per cent, of 
the patients, due to involvement of the chorda tympani 
in the middle ear. In a small percentage there is also a 
loss of taste sense on the posterior third of the tongue, 
soft palate or fauces, which is attributed to involvement 
of the tympanic plexus as it lies on the internal tympanic 
wall. 

Pain is not present unless there are complications or 
acute exacerbations; yet discomfort and intermittent 
pains are at times complained of. Vertigo should always 
lead one to suspect some labyrinthine involvement, 
although it sometimes occurs after syringing the ear, due 
no doubt to disturbance at the labyrinthine fenestrse or to 
the temperature of the solution acting as in the caloric test. 

Signs. — In making an examination of the fundus of the 
external auditory canal, one endeavors not only to locate 
the loss of integrity of the drum membrane which usually 
exists, but to form some conception of the nature, extent, 
and location of the process, which will guide him in deter- 
mining the prognosis and treatment. While wiping away 
the secretion its amount, character and source are noted, 
and in forming an opinion as to the lesion causing it, the 
length of time it has persisted and whether continuous 
or intermittent, has a distinct bearing. Perforations of 
the drum membrane in O. M. P. C. may be divided into 
three classes: 



SIGNS 253 

1. Large perforations of the membrana tensa permitting 
a view of the internal tympanic wall. 

2. Small perforations of the membrana tensa. 

3. Perforations involving Shrapnell's membrane. 
Large Perforations, — Large perforations permitting a 

view of the internal tympanic wall present considerable 
variation: (a) the membrana tensa may be nearly com- 
pletely destroyed, a small margin only of the membrane 
left along the tympanic ring, or this margin may be absent 
at some part of the segment; (b) only the central part 
may be destroyed when the perforation is usually more or 
less kidney-shaped, the manubrium projecting into what 
corresponds to the hilum of the kidney. This process 
may be either intact, in which event there is usually a 
substantial margin of membrane attached to it, or it may 
be more or less necrosed; (c) the posterior part of the 
membrane may be absent, the anterior part either not 
having been destroyed, or if this took place, it has reformed 
with cicatricial tissue. In total loss of the drum mem- 
brane (a) the manubrium may either be present or have 
sloughed away from disease. If it is absent, the process 
has usually invaded the tympanic vault. If present, it 
is usually adherent to the internal tympanic wall and at 
times seems much broader than normal. This is due to 
rotation of the ossicle so that the short process points 
more forward than normal. In large posterior perfora- 
tions it usually lies in the anterior margin of the perfora- 
tion attached to the inner wall of the tympanum. In 
these, as well as in those which involve nearly the whole 
of the membrana tensa, the long process of the incus 
attached to the stapes may be seen, or if the former has 
necrosed, the stapes alone may be present. One frequently 
sees these large perforations, which have become healed 
with cicatricial drum membrane, more or less adherent 
to the internal tympanic wall, or dermatized posteriorly 
and membrane anteriorly, the ear being dry. So they are 
not in themselves of serious import. Dermatization in 
a kidney-shaped perforation usually takes place by the mar- 



254 OTITIS MEDIA PURULENT A CHRONICA 

gins of the perforation adhering to the internal tympanic 
wall which then dermatizes over the area of the perfora- 
tion. When this occurs the ear becomes dry. These 
kidney-shaped perforations are more common with tubal 
involvement, and patients with them often give the 
history of intermittent discharge. The ear will be dry 
except for a few days or weeks in each year, or they may 
respond rapidly to treatment, as in the case of the patient 
whose fundus is shown in Figure 70. Nevertheless, the 
discharge may come from the vault and antrum in this 
type of perforation; still, unless contraindicated for 
some special reason, patients with this type of perfora- 
tion are entitled to a thorough trial of non-operative 



i 



ft* 



I 



Fig. 76. — Kidney-shaped pcii' i u i u. From a patient of the author. 
History of short attacks of suppuration l^etween which the ear was 
dry. 

treatment. The following remarks apply to classes a 
and by that is, nearly total destruction of the membrana 
tensa or large posterior perforations. If the internal 
tympanic wall is dermatized and there is a purulent 
discharge, it must be coming from the vault and antrum, 
as the Eustachian tube is usually closed. A sinus will 
often be found leading beneath the posterior fold (Fig. 
77). An odorous discharge in such a process seldom ceases 
without operation. Patients with this fundus condition 
are not infrequently seen who have resorted to all sorts 
of local treatment for years without relief. In operating 
upon them cholesteatomatous masses are not infrequently 
found. The internal wall may be dermatized and the 



SIGNS 255 

patient have an intermittent discharge, coincident with 
an acute nasopharyngeal process, but this is not common. 
In them the dermatized area over the tube breaks down 
with the tubal infection and discharge occurs for a short 
time only. The internal tympanic wall may be covered 
with mucous membrane which is reddened and thickened. 
It may be difficult at times to distinguish this from an 
inflamed tympanic membrane, and in fact incisions have 
been made under this misinterpretation. When the 
membrane is not markedly diseased, the pus may be 
coming from the Eustachian tube. One may be able to 
determine this by drying the cavity, then inflating, when, 



~^'^ 




Fig. 77. — Large perforation — marginal posteriorlj^ Continuous sup- 
puration for years. Pus discharging through a sinus beneath the 
posterior fold. Internal tympanic wall dermatized. Radical operation 
showed granulations and cholesteatomatous masses in the vault and 
antrum. 

if the tube is responsible for the discharge, it will be 
forced into view. Patients in whom this is the case are 
more apt to show recurrences, being well for periods 
varying from one month to a year, then having discharge 
for a few months or so. The attacks doubtless being 
caused by reinfection of the tube. The discharge is usually 
mucopurulent and without odor, and the process offers 
encouragement for the success of treatment directed to 
the tube and nasopharynx. If pus is not forced from the 
tube upon inflation, the otoscope may be tried, when, 
by rarefying the air, pus may be drawn from the vault 
and antrum. If this is the case, it will usually be found 



256 OTITIS MEDIA PURULENTA CHRONICA 

that the discharge has been constant and possesses odor. 
Such a process offers very httle encouragement for local 
treatment. Granulations may spring from the internal 
tympanic wall. If this is the case, an attempt may be 
made to relieve the process by local treatment, but it 
will usually be without success. The patient from whom 
Fig. 78 was taken was treated for six months without 
any relief. At the operation the foot-plate of the stapes 
was found necrosed, the ossicle lying in the mass of granu- 
lations. Polypi may spring from the internal tympanic 
wall or from the vault and appear in the canal. When 
they are present they must be removed before a view of 
the parts can be obtained. The occurrence of a polyp 



.:^^ 



>m^ 



Fig. 78. — Large posterior perforation. Granulations in the region of 
the oval window. 

usually indicates that very little may be expected from 
non-operative treatment. 

Small Perforations. — Small perforations of the mem- 
brana tensa allow no part, or at most a very small one, of 
the internal tympanic wall to be seen, so one must judge 
of the condition of the tympanum and antrum by the 
character of the discharge and the appearance and loca- 
tion of the perforation. These may exist with clean-cut 
edges or granulations may spring from their margins and 
more or less fill the opening, or forcing themselves through, 
produce a red prominence on the surface of the drum 
membrane. These granulations usually occur in processes 
which do not respond so readily to local treatment. 



SIGNS 257 

According to location, small perforations may be divided 
into several classes. 

(a) Openings in the anterior part or near the center 
of the drum membrane. The discharge in these per- 
forations is apt to be mucopurulent and more or less 
intermittent. The patient from whom Fig. 79 was 
drawn had discharge for about two or three weeks in 
each year for a number of years. Each attack occurred 
with an acute nasopharyngeal involvement and was, no 
doubt, due to tubal disease. One should treat a patient 
with the small central or anterior perforations non- 
operatively until experience with the individual process 
teaches him that his efforts are fruitless. 




Fig. 79. — Small central perforation. 

(b) The perforation has a different significance if it 
occurs at the margin of Shrapnell's membrane, and is 
then apt to be associated with processes in the vault and 
antrum which discourage one from expecting much from 
local treatment. 

(c) ^Marginal perforations are usually associated with 
severe processes. There are apt to be extensive granula- 
tions, necrosis of bone, or cholesteatoma. Besides the 
small marginal perforations (Fig. 80) the large perfora- 
tions often derive a certain amount of significance from 
the fact that they encroach upon the tympanic ring, and 
may on this account be alluded to as marginal perfora- 
tions. An opening in the membrana tympani which is 
located near the tympanic ring may, at times, easily be 

17 



258 OTITIS MEDIA PURULENTA CHRONICA 

mistaken for a marginal one. Therefore one must be 
absolutely certain that no drum membrane exists between 
the opening and the ring. Marginal perforations as a 
rule offer very little prospect of cure by local (non-opera- 
tive) treatment. 

(d) Perforations in the posterosuperior quadrant are 
as a rule associated with involvement of the vault and 
antrum, the path of drainage being along the long process 
of the incus. When the discharge has been continuous 
and possesses odor, these perforations usually indicate 
the necessity of a radical operation. 

(e) Multiple perforations, while not pathognomonic 
of tuberculosis of the middle ear, usually only occur in 






Fig. 80. — Small marginal perforation. The patient whose drum 
membrane is shown had a continuous odorous discharge for years. 
Operation revealed the tympanum and antrum full of granulations. 

this disease, and should therefore, when present, excite 
suspicion that the process is of this nature. 

Perforations Involving ShrapnelVs Membrane. — Per- 
forations situated either wholly or partly in ShrapnelFs 
membrane, while not as common as those in the other 
parts of the membrana tympani, are of great importance 
and may easily be overlooked unless one forms the habit 
of carefully inspecting this part of the fundus in every 
patient. In many of these perforations the secretion is 
scanty, frequently not sufficient being discharged to 
appear at the external end of the meatus, but it dries in 
crusts near the perforation in the depth of the canal. 
Many perforations may not be seen if these crusts, which 



SIGNS 259 

either cover the opening or granulations conceahng it, 
are not removed. When patients come complaining of 
deafness, tinnitus or a full feeling in the ears and crusts 
are discovered, a perforation will not infrequently be 
found to be present, although the history of a discharge 
is absent. Perforations in Slirapnell's membrane may be 
divided into two general classes : (a) those which involve 
the membrana tensa and extend into Shrapnell's; (6) 
those which involve Shrapnell's membrane but do not 
extend into the membrana tensa. 

(a) In the former the 'defect in the membrana tensa 
may be either the large or small type. If large, the usual 
location is in the posterior part of the membrane, the 




Fig. 81. — Large posterior perforation extending into Shrapnell's. 
The head of the malleus is exposed. In this patient the radical operation 
showed a large antrum full of granulations. The discharge possessing 
odor had been continuous for many years. 

defect in ShrapnelFs being near the malleus, as in Fig. 
81, or more posteriorly near the margin of the Rivinian 
segment. The internal tympanic wall may be dermatized 
and show more or less distinctly the anatomical arrange- 
ment, as in Fig. 81; or it may be covered with thickened 
mucous membrane in any stage of granulation or pohp- 
oid formation. Very rarely these perforations extend 
into Shrapnell's anterior to the manubrium. They have 
the same significance in either case. The discharge is 
apt to be freer than in perforations limited to the mem- 
brana flaccida. They are as a rule associated with granu- 
lations, necrosis of bone or cholesteatoma in the vault 



260 OTITIS MEDIA PURULENT A CHRONICA 

and antrum — processes which require operation for their 
cure. 

If the defect in Shrapnell's is a part of a small perfora- 
tion, the location may be either on the posterior or 
anterior folds, the former being oftener seen. Sufficient 
of the membrana flaccida is destroyed to open the vault, 
and it is from this location that the pus comes. The 
processes which they accompany are the same as in those 
limited to Shrapnell's and usually require operation for 
their cure. 

(6) Of the perforations in Shrapnell's many are on the 
margin of the Rivinian segment and are more apt to con- 




FiG. 82. — Perforation (filled with granulations) on the margin of 
Shrapnell's. The patient had scanty odorous discharge for years. Opera- 
tion showed necrosis of the walls of the vault; cholesteatoma and granu- 
lations filling the vault and antrum. The membrana tensa was practi- 
cally normal. 

tain granulation tissue than those more centrally located. 
The membrana tensa may be practically normal, as in 
the patient whose membrane is shown in Fig. 82; or more 
or less cicatricial, showing that the process has exhausted 
itself in the atrium but continued in the vault and antrum. 
These perforations may extend into the dermal layer of 
the superior canal wall. A lesion which while perhaps not 
anatomically of this class yet clinically is so closely related 
that it belongs here, is a perforation through the integu- 
ment on the canal wall adjacent to the membrana flac- 
cida. The purulent secretion, dissecting its way out 
beneath the periosteum, ruptures through the canal wall 
or extension of necrosis of bone from the margin of the 



COMPLICATIONS 261 

vault may be responsible for their formation. They 
are usually filled with granulations, but a small probe 
may be passed into the vault. Both of these types of 
perforations are apt to be associated with cholesteatoma, 
caries of the walls, and granulations in the vault and 
antrum. In many of them the antrum seems to be 
enlarged, and this outside of the changes due to choles- 
teatoma. They indicate operation. 

Central perforations of ShrapnelFs may be of sufficient 
size to expose the head of the malleus or very much smaller, 
their presence being revealed only upon close inspection. 
At times, granulations are evident in the depth of the 
perforation, on its margins or pouting into the canal, 
completely filling the opening in Shrapnell's. The secre- 
tion is usually scanty and of foul odor, drying into crusts. 
Usually, an operation is required for the accompanying 
disease in the vault and antrum. Patients with healed 
perforations in Sln*apnell's have been seen by Politzer. 
At times one feels that a condition producing such a small 
perforation and so scanty a discharge cannot be of a very 
serious natm-e; but this impression is not justifiable. 
The author has yet to see an operation performed for a 
process with a perforation in Shrapnell's, in which the 
findings did not justify the procedure. 

Perforation in Prussak's Space. — One form of perfora- 
tion in Shrapnell's occasionally seen is due to an exliausted 
suppuration in Prussak's space. The perforation is dry 
and merely the result of an inflammation limited to this 
space, in which its external wall has been destroyed. The 
neck of the malleus forms the bottom of the depression. 
It is really a residual process and is mentioned in this place 
that it ma}' not be confused with real perforations in 
Shrapnell's which are of serious import. 

Complications. — A chronic suppurative process may 
at any time develop a complication. The aural pus 
from chronic suppurating ears usually contains epithelial 
masses, round cells, saphrophytic microorganisms and a 
variety of bacilli, but during an acute exacerbation some 



262 OTITIS MEDIA PURULENTA CHRONICA 

of the microorganisms associated with acute processes 
are usually present, such as streptococcus, pneumococcus, 
etc. This justifies the belief that the cause of an acute 
exacerbation is an acute infection engrafted upon the 
chronic process. The discharge usually increases in 
amount and becomes frankly purulent. In these acute 
exacerbations the process acts very much as an acute 
purulent otitis media. There is pain and fever and the 
mastoid very frequently becomes involved. The condi- 
tion is properly considered as being a serious one on 
account of the danger of intracranial complications or 
labyrinthitis, which are more common with acute exacer- 
bations of a chronic process than with the simple acute 
otitis media. When the mastoid becomes involved under 
these circumstances, no time should be lost in waiting to 
see if it will not resolve, but the operation should be done 
at once. By this means further complications may, if 
possible, be prevented. The procedure demanded in 
these patients is usually the radical operation, although 
under exceptional circumstances one may be justified in 
first performing the simple mastoid and then later the 
radical if necessary, which it usually will be. The other 
complications of chronic suppuration are labyrinthitis, 
meningitis, sinus thrombosis and brain abscess. They 
are discussed in separate chapters. 

Diagnosis. — The diagnosis as a rule is not difficult. 
That the patient has an O. M. P. C. is shown by the 
presence of a discharge which has existed for over three 
months, and the loss of integrity of the drum membrane, 
or, in rare instances, a perforation on the canal wall 
giving exit to the pus. If one is not careful one may fail 
to make a diagnosis in those patients with scanty dis- 
charge, drying in crusts upon the canal wall. These types 
are described under Perforations Involving ShrapnelFs 
Membrane. An attempt has been made to show what, 
more than the simple fact that the patient has O. ]\I. P. C, 
may be learned from the study of the fundus appearance. 
In making out cholesteatomatous processes, if one is 



TREATMENT 263 

able to remove some of the material from the middle ear, 
its appearance and odor are characteristic. ^Microscopic 
examination shows the presence of cholesterin crystals, 
epithelial debris, perhaps also the nests. Cholesterin 
crystals may be found in epithelial masses coming from 
the meatus, but the nests or the fact that the mass sub- 
mitted to examination was taken from the middle ear 
establishes the nature of the process. 

Prognosis. — The prognosis is serious in processes involv- 
ing the vault and antrum, less so in those patients in whom 
these parts are not involved and the discharge is inter- 
mittent. While many patients with the former type may 
live for years, still the disease is more of a menace to life 
and health than is generally supposed. Pathologists 
performing autopsies in the large city morgues state that 
the cause of death is some complication of chronic purulent 
otitis media, in a much larger proportion of cases than is 
generally supposed. From the description of the disease 
as given above, one should be able, insofar as it is possible, 
to separate those processes which are a menace to life 
and health from those which are more benign in their 
effects. In a great many patients the disease can be 
cured either by local treatment or by operation, still the 
prognosis as given to the patient should be a guarded one. 

Treatment. — When one is able to find and remove the 
cause of the suppuration, it is the first step in treating 
the patient. When adenoids are responsible, much may 
be expected from their removal, especially if the middle- 
ear process is mainly confined to the atrium and tube. 
They should be thoroughly removed and the tonsils 
enucleated at the same time if they are enlarged or small 
and infected. Any other abnormal condition of the 
nose, nasopharynx or accessory sinuses may be attended 
to, but not much improvement of the aural condition 
may be expected to be produced by doing so — at least 
not in comparison with that which often follows the 
removal of the adenoids. 

The general health is to be attended to in order to 



264 OTITIS MEDIA PURULENTA CHRONICA 

increase the resistance. With this end in view, vaccine 
therapy has been tried, and while much was expected from 
it, the results have been disappointing. Benefit has been 
reported in some instances, but the general opinion of 
aurists is that it is without marked value. The author's 
experience does not encourage him to expect much from 
this mode of treatment. There are so many germs in 
a chronic discharge that the difficulty of growing the one, 
if there is one, which is responsible for the disease is very 
great. Perhaps bacteriologists will eventually overcome 
the difficulties and furnish the aurist with a remedy of 
value. 

In treating the disease great attention must be given 
to cleanliness. The discharge must be thoroughly 
removed. The best way to do this is by syringing with 
antiseptic solutions. Bichloride of mercury, 1 to 4000, 
or a saturated solution of boracic acid, seem to fulfil 
the requirements. The frequency of syringing depends 
upon the amount of discharge; usually four times a day 
is sufficient. If there are pockets of pus that this fails 
to reach, peroxide of hydrogen, the ten-volume solution 
diluted one-half, may be instilled ten minutes before 
syringing the ear. There seems to be no danger in using 
this peroxide solution. In large perforations good results 
are often obtained by the instillation of alcohol. A 1 
to 2000 bichloride solution in 50 per cent, alcohol is used 
and ten drops are instilled twice a day, the patient hold- 
ing the head well to the opposite side, that the solution 
may come in contact with the intratympanic structures 
to as great a degree as possible. After the patient is 
accustomed to the use of this strength of alcohol, it may 
gradually be increased until 95 per cent, alcohol is used 
or pain is produced. When there is reason to suppose 
that the Eustachian tube is diseased, inflation followed 
by the application of nitrate of silver or argyrol solution 
to the tubal mucosa may produce good results. (For 
method see Tubal Catarrh.) An attic syringe (Fig. 83) 
may be used to cleanse the vault and antrum. This is 



TREATMENT 



265 



a small syringe with a curved point which is inserted 
through the perforation and directed upward. Dilute 
alcohol is used in this manner, as it more readily brings 
away the cholesteatomatous masses than water, which 
may cause them to swell. Granulations, if within reach, 
may be cauterized with a fused bead of silver nitrate 
or removed with the sharp ring curette. 




Fig. 83. — Blake's attic syringe. 



Dry Treatment, — Sometimes the insufflation of boric 
acid is of value, especially if large perforations are present. 
The treatment, at one time in vogue, of filling the canal 
with powder is to be condemned, as by absorbing the 
secretion it may harden and close the perforation or canal 
and thus interfere with drainage and produce dangerous 
complications. 

Removal of Polypus, — If a polypus is present, it should 
be removed. In many instances polypi are of sufficient 
size to require removal before an examination of the 



266 OTITIS MEDIA PURULENTA CHRONICA 

fundus of the meatus is possible. The large variety which 
project well toward the entrance of the meatus are usually 
best taken with the snare. One with as small, a cannula 
as will carry a stiff wire is most conveniently used. The 
loop is placed over the growth and gently pressed well 
to the fundus of the canal. Gentle traction on the growth 
while the loop is being passed will prevent its folding upon 
itself in front of the loop, which will make it difficult 
to reach the fundus with this part of the instrument. 
All of the manipulation should be very gently performed 
and, on account of its painful nature, it is frequently 
advisable to administer gas. The loop, being in position, 
is now drawn home and the growth severed without 
exerting any traction. The canal may now be packed 
with cotton saturated with adrenalin to stop the hemor- 
rhage. This being accomplished, the base of the polyp 



Fig. 84. — Sharp ring curettes. 

is examined to ascertain if sufficient has been taken. For 
removal of this base, or for a somewhat sessile polypi, 
or as a matter of preference in any form, the sharp ring 
curette may be used (Fig. 84). It is usually necessary 
to use one with a large ring and a narrow^ band so that 
the fenestra may be as large as possible. After deter- 
mining the attachment of the growth, the ring is worked 
over the polyp and pressed as near to the location of the 
attachment as possible and this is severed by forcing the 
cutting edge of the curette through it. A polyp should 
never be torn away, as no one can foreknow the exact 
location to which it is attached. It may spring from 
the tegmen tympani and its evulsion may result in injury 
through which infection may reach the meninges. A 
number of deaths have been caused in this way. After 
removal of a polyp the patient should be kept under 
close observation for twenty-four to forty-eight hours. 



INDICATIONS FOR OPERATION 267 

so that should complications arise they may be promptly 
treated. 

Indications for Operation. — After persevering in the 
treatment of an O. INI. P. C. for a time without improve- 
ment, the question of operation arises. An attempt has 
been made, under fundus appearances, to show in what 
processes one may hope for a cure by other means. In 
addition to these, the discharge affords information. 
Some patients with a discharge of foul odor, which has 
existed for years, with fundus changes indicating that the 
pus comes from the vault or antrum, should be operated 
without preliminary treatment. Others, who do not 
have these fundus changes, in whom the discharge has 
not existed so long, and especially if they give a history 
of periods of cessation of the discharge, are entitled to a 
faithful attempt to secure a cure without operation. No 
fixed time can be given either for duration of the discharge 
or continuance of treatment before an operation becomes 
advisable. \Yhen one feels certain that local treatment is 
a failure, and that the process is of such a nature that 
the health is menaced or complications are threatened, 
it is time to operate. Cholesteatomatous processes 
practically always demand operation. 

Form of Operation, — Before deciding upon the radical 
operation, it would seem wase to consider whether or not 
minor surgical procedures might not result in a cure. 
Several measures have been advocated, some of which 
are still on probation, while others have given place to 
procedures more certain of results. They may be divided 
into three classes: 

1. Those which are intended to produce closure of the 
Eustachian tube. 

2. Those intended to remove necrotic bone (mainly 
the ossicles) through the external auditory meatus. 

3. x\ modified radical operation which for the sake 
of producing less impairment of hearing, while opening 
the antrum, leaves undisturbed the ossicles and drum 
membrane. 



268 OTITIS MEDIA PURULENTA CHRONICA 

Tubal Closure. — In those patients whose middle-ear 
suppuration continues on account of some condition 
existing in the Eustachian tube, there can be no doubt 
but that permanent closure of the tube is desirable. 
Yankauer^ has devised an operation which is intended 
to produce closure of the osseous portion of the tube. 
By means of a specially designed curette he removes the 
mucous membrane lining the tube from the tympanum 
to, and including, the isthmus. If the operation is suc- 
cessful, this portion of the tube becomes filled with cica- 
tricial tissue. While too much has been expected of this 
operation, and it has, no doubt, been performed in many 
unsuitable cases, still it promises to be a procedure of 
value. The type of processes in which it should be of 
value are those in which local treatment usually improves 
the condition and it remains more or less quiescent until 
lighted up by a fresh infection, occurring through the 
Eustachian tube. It is difficult to see how closure of the 
tube would be of any value when the vault and antrum 
are filled with granulations or cholesteatomatous masses 
and their walls the seat of bone necrosis or caries, many 
of which processes persist long after nature has perman- 
ently closed the tube at its tympanic orifice. 

Yaukauers Operation, — The operation is performed by 
anesthetizing the tube and middle ear, after which, if 
necessary to gain access to the tube, a flap of drum mem- 
brane is removed. The mucous membrane is then curetted 
from the osseous portion of the tube by Yankauer's 
curette, introduced through the meatus. Care should 
be taken not to use much force in an inward direction, 
as the carotid artery is in the immediate proximity, and 
while the artery has not so far been wounded, the bone 
has been removed from it in a patient coming under the 
author's observation. 

Other Methods of Tubal Closure. — Mosher has attempted 
to close the tube from the pharyngeal end by applications 

1 Laryngoscope, July, 1910. 



OSSICULECTOMY 269 

of silver nitrate in strong solution. The subject of tubal 
closure is one that is attracting the attention of aural 
surgeons, and progress in this line may reasonably be 
expected. As a preliminary to the radical operation and 
subsequent to it in those patients who are not completely 
relieved of their discharge on account of the tube remain- 
ing open, some method or form of treatment which will 
produce permanent closure of the tube is desirable. 

OSSICULECTOMY. 

The second class of these operations is the removal of 
the malleus and incus with the remains of the tympanic 
membrane. This procedure may at times be adopted with 
success. 

Indications. — It is indicated in those processes which 
are due to necrosis of the ossicles and when it is believed 
that the increased drainage of the vault and antrum 
afforded by their removal may result in cure of the pro- 
cess. It is at times possible to make out necrosis of the 
manubrium by inspection. Necrosis of the incus may 
be suspected if a large posterior defect in the membrana 
tympani enables one to see the stapes in position with 
the long process of the incus absent. Unfortunately, 
one cannot be sure that the remains of the incus are still 
present or that they have any influence on the suppura- 
tive process. Perforations in Shrapnell's may exist 
through which necrosis of the ossicles may be made out. 
However, when these conditions are present, as well as 
in patients in whom they are absent, the involvement of 
the ossicles may be such a small part of the process that 
their removal does not have much influence for good. 
As compared with the radical operation, by means of 
which every part of the tympanum and antrum is exposed 
and becomes accessible, ossiculectomy is a weak proced- 
ure. As for removing granulations from the vault, as 
advised by many advocates of the operation, it is not 
free from danger. So the operation when performed 



270 OTITIS MEDIA PURULENT A CHRONICA 

should be limited to the removal of the malleus and incus 
with the remains of the drum membrane, and curetting 
any granulations which may exist in the lower part of 
the tympanic cavity. 

Anesthesia. — The middle ear is thoroughly douched 
with bichloride solution before operation. Children and 
nervous subjects require general anesthesia. The opera- 
tion, however, can be made practically painless by local 
anesthesia which is induced as follows: A few minims 
of a 10 per cent, solution of cocaine is instilled into the 
middle ear through the perforation and allowed to remain 
ten minutes. If the defect in the drum membrane is a 
large one, a pledget of cotton saturated with the solution 
is placed in contact with the internal tympanic wall. 
This aids in making the operation painless by producing 
anesthesia of the mucous membrane with which the 
solution comes in contact, but the main reliance is placed 
upon the hypodermic injection of one-half of 1 per 
cent, solution of cocaine to which two or three drops of 
adrenalin have been added to each cubic centimeter. 
The needle is entered upon the superior wall of the canal 
at the juncture of the osseous and cartilaginous meatus 
and a few drops forced out at a time as the needle travels 
along the bone to the internal end of the osseous meatus. 
Anesthesia becomes complete in about ten minutes. 

Operation. — ^The instruments advised are Politzer's 
ossiculectomy set (Fig. 85). The largest speculum 
possible is now inserted and the operation performed 
under brilliant illumination. The tympanic membrane 
is completely separated from the tympanic ring by a 
small scalpel. It is well to start this with a knife having 
a very sharp point, then to substitute one with a probe 
point in order not to wound the mucous membrane, and 
thus increase the hemorrhage. 

The next step is dividing the incudostapedial articula- 
tion. This will not be necessary if there has been necrosis 
and sloughing of the long process of the incus. This is 
accomplished with a small knife, the blade of which is 



OSSICULECTOMY 



271 



at a right angle with the shaft. This is inserted from in 
front between the long process of the incus and the 
internal tympanic wall with which the flat of the blade 
is in contact. Upon rotation of the instrument, the blade 
moves downward and severs the connection between 
the incus and stapes. If there is an adhesion between 
the manubrium and the internal tympanic wall, it may be 
divided in the same manner; or a ring knife, resembling 



f) 



rO €>i 



^ '^^'^ 




Fig. 85. — The Politzer set of instruments for performing ossiculectomy. 



the sharp ring curette, may be slipped over the end of the 
manubrium with the cutting edge upward, and gradually 
forced tln^ough the adhesion, or if there is no adhesion, 
this instrument gradually worked upward will sever the 
tendon of the tensor tympani and the ligaments hold- 
ing the malleus in position. This loosens the ossicle 
and it may be delivered with a small angular forceps. 
The incus is now removed with a hook designed for 



272 OTITIS MEDIA PURULENTA CHRONICA 

that purpose. These hooks are made right and left. 
Selecting the appropriate one, it is worked up posterior 
to the ossicle, then by rotating the instrument, the hook 
with the incus engaged is brought down into the atrium 
and removed with the forceps. Considerable skill is at 





Fig. 86. — Dench ear punch. 

times necessary to remove this ossicle, as it may be forced 
into the antrum or lie concealed internal to the tympanic 
ring. If it escapes into the former location, it cannot be 
removed; if in the latter, a careful search will enable the 
surgeon to find and remove it. Care should be taken 



OSSICULECTOMY 273 

when inserting the hook not to disturb the stapes or 
structures in the oval window, and no traumatism should 
be inflicted upon the Fallopian canal or facial paralysis 
may result. 

The granulations in the atrium may be removed with 
curettes, taking care not to wound the facial nerve. An 
attempt may also be made to close the orifice of the Eus- 
tachian tube by curetting the mucous membrane at its 
tympanic orifice. If the internal end of the superior 
canal w^all is prominent, it may be removed with a properly 
designed biting forceps (Fig. 86). By thus taking away 
the prominent margin of the Rivinian segment much 
better drainage of the vault and antrum is secured. As 
stated above, it cannot be considered a safe procedure 
to attempt to do much curetting in the tympanic vault. 
It is well at the outset to acknowledge the limitations 
of this procedure and not try to accomplish with it that 
which can only with safety be accomplished by the 
radical operation. 

After-treatment.— Having completed the operation, the 
ear is syringed with normal saline or bichloride solution 
and a strand of iodoformized gauze lightly packed into 
the tympanum. Sterile gauze, cotton and a bandage 
complete the dressing. This may be changed daily for a few 
days, after w^hich the ear is left open and regularly irrigated. 

Accidents. — Accidents which have occurred are as 
follows: facial paralysis from wounding the nerve as it 
lies in the internal tympanic wall; injury to the jugular 
bulb either in attempting to remove necrotic areas from 
the tympanic floor or in curetting in this location when a 
dehiscence was present; meningitis from injury to the 
structures in relation to the tegmen tympani, produced 
while attempting to remove granulations from the vault. 
The chorda tympani is always divided and permanent 
loss of taste sense results on the anterior two-thirds of the 
tongue. The patient is not usually conscious of this 
fact, and as it is present in about 50 per cent, before the 
operation, it cannot be considered of importance. 
18 



274 OTITIS MEDIA PURULENT A CHRONICA 

Results. — Some patients are cured of the discharge. 
The proportion is, however, small as compared with the 
radical operation which frequently is required later. 
Some are benefited to a greater or less extent, while a 
a considerable proportion show no improvement. This 
uncertainty of result, and the feeling which the surgeon 
has that he cannot be certain that he is removing all of 
the diseased tissues, have been responsible for the lack 
of popularity of this operation. 

Modification for Non-suppurative Cases. — The operation 
when performed in a non-suppurative ear to increase the 
hearing is in the main as described above, with this 
exception, that care is taken not to wound the mucous 
membrane except to divide adhesions in the niche of the 
oval and round windows. The ring knife is not used, as 
it inflicts too much traumatism. The tensor tympani 
is divided w^ith the angular knife and the ossicles carefully 
delivered. In the after-treatment irrigations are not 
used unless absolutely necessary on account of infection. 
If the drum membrane reforms it must be removed a 
second time, as the success of the procedure rests upon 
having it absent. 

Modified Radical. — The third class of operations is 
discussed under the head of INIodified Radical Operation 
after the Radical Operation. 

THE RADICAL MASTOID OPERATION. 

Instruments. — The instruments needed for the perform- 
ance of the radical operation are the same as for the 
simple mastoid, and the following in addition: 

1. Two Richard curettes (Fig. 87), small and medium- 
sized. These are bent in the shank and are very useful 
for scraping away hard bone. 

2. One small chisel. 

3. One small curette for use in the tympanic opening 
of the Eustachian tube. 

4. One sharp ring curette with flexible shaft. 



THE RADICAL MASTOID OPERATION 275 

5. One long narrow-bladed knife for cutting the meatal 
flap. 

Preparation of Patient. — The preparation of the patient 
is in general the same as for the simple mastoid operation. 
As the radical operation is not so frequently an emer- 
gency procedure, usually sufficient time is aft'orded to 
thoroughly prepare the patient. He should be admitted 
to the hospital the day before and a thorough test of the 
aural functions made. The amount of hearing, the 
upper- and lower-tone limits and the tuning-fork tests 
for bone conduction aftords a basis for judging of the 
condition of the acoustic labyrinth, and also gives data 
for comparison as to the results of the operation. The 
rotation, caloric and fistula tests should be made as 
having an important bearmg on the kind of operative 



Fig. 87. — Richard's curette. 

procedure adopted, and also in studying any labyrinthine 
complications or symptoms which may arise later (see 
Suppurative Disease of Labyrinth). If it is proposed to 
insert a Thiersch graft, the thigh should be prepared the 
night before if possible. The left is usually selected as 
being slightly more convenient than the right. It is 
scrubbed with soap and water, shaved, washed with 
alcohol and done up in antiseptic dressings. 

The patient should have a general anesthetic. The 
position of the assistants and surgeon is the same as in 
the simple mastoid operation. 

Incision. — The incision varies slightly from that in 
simple mastoidectomy. It can be started a trifle higher 
than the apex of the tip and does not go through the 
muscle to the bone at its lower end. As it is extended 
upward, it is made a trifle more posteriorly and its upper 



276 OTITIS MEDIA PURULENTA CHRONICA 

end is carried slightly more forward. * It extends to the 
bone in the middle of its course and through the tem- 
poral fascia where it lies over that muscle. It is made 
more posteriorly in order that as the flaps are sutured in 
completing the operation the line of junction may overlie 
the bone and not the radical cavity. This facilitates 
healing and enables one to place the grafts properly. The 
incision is extended farther forward above the ear, as it 
is necessary in this operation to have a much greater 
exposure of the upper wall of the canal and the ear must 
be drawn farther forward to aft'ord this exposure. 

Exposing the Field. — x\fter completing the incision all 
of the bleeding-points are caught with hemostat forceps. 
The anterior flap is pushed forward with the periosteal 
elevator, exposing the posterior and superior margins 
of the meatus and the anterior retractor inserted. The 
fibers of the temporal muscle are elevated in an upward 
and forward direction. The ear can usually be drawn 
sufficiently forward with incision of the temporal fascia, 
but if necessary to expose the upper margin of the bony 
meatus the muscle also may be freely incised. Unless 
the fibers of the sternomastoid are attached unusually 
high on the surface of the mastoid, they need not be 
elevated. The skin and periosteum is now separated 
from the external auditory canal over the superior and 
posterior walls, but the anterior wall should be undis- 
turbed. The posterior margin of the incision may be 
elevated at any time if more room is required. 

Opening of the Antrum. — One who has been accustomed 
to performing the simple mastoid, must not be surprised 
if he does not encounter cells, as the bones in processes 
requiring the radical operation are apt to be of the sclerotic 
or infantile type. In the latter type the sinus may be 
well forward and the middle fossa low. There are no 
constant landmarks on the bone which indicate the 
position of these structures. A low temporal ridge or a 
shelving upper canal wall are very apt, however, to be 
associated with a low middle fossa. The Dench triangle 



THE RADICAL MASTOID OPERATION 277 

is located (Fig. 69). This overlies the antrum which will 
be opened at a depth of three-eighths to one-half inch, 
varying to a certain extent with the size of the antrum. 
These measurements are from dry bones. One seems at 
times to go deeper than this before opening the antrum. 
If the posterior wall of the canal extends forward as it 
approaches the drum membrane, the antrum will be 
forward since it lies contiguous to the junction of the 
superior and posterior walls of the meatus very near the 
insertion of the tympanic membrane. So in working in 
a bone with a shelving posterior w^all, as above described, 
one must work forward. To use the gouge and excavate 
perpendicular to the surface of the mastoid with such a 
configuration of the parts would endanger the sinus if 
it is located far forward. Frequently, the antrum is large 
and offers no difficulty. But a small antrum, deeply 
placed and especially with a shelving posterior canal 
wall, is certain to be trying to a surgeon of limited experi- 
ence in this operation. . A large-sized gouge is used and 
a shaving is taken, starting upon the surface of the mas- 
toid, very near the margin of the meatus. The upper 
edge of the shaving is in the triangle and the lower is 
tow^ard the floor of the canal. The gouge is very nearly 
parallel with the posterior wall of the canal, and the first 
shaving is largely composed of the canal wall. By taking 
repeated shavings in this manner, one works a gutter in 
the posterior canal wall, about one-fourth inch in length, 
that is, measured from the mastoid surface toward the 
drum. In working backward each shaving is carefully 
taken, as the sinus may be exposed at any time when, 
of course, further progress in this direction is impossible. 
If the sinus should not be so far forward, one deepens 
the gutter backward only enough to afford sufficient room 
to excavate a pit in its internal end, which naturally 
is toward the antrum. By forming this gutter the triangle 
has been moved from the surface of the mastoid, inward 
the length of the gutter, and it is therefore that much 
nearer the antrum. It is in the offset which forms the 



278 OTITIS MEDIA PURULENTA CHRONICA 

inner end of the gutter and in the triangle adjacent to 
the union of the superior and posterior walls that a pit 
is now excavated, with a small gouge, to open the antrum. 
It may be that this cavity or soft bone overlying it has 
already been encountered; if so, the opening is enlarged 
with the curette. If not, the pit is deepened, working 
parallel with but not taking down the canal wall, until 
the antrum is opened. One must keep in the triangle 




Fig. 88. — Radical operation. Antrum opened with curved probe 

inserted. 



in deepening the pit. If one works too high, the middle 
fossa will be opened; if too low, the antrum will be missed 
and the facial nerve endangered if the excavation is 
carried deeply enough. Fortunately, the very small 
antra which require this great care are not the rule. 
That the antrum has been opened may be known from 
the fact that a bent probe readily passes forward into 
the vault (Fig. 88). After the antrum is opened, or 
before, if difficulty is experienced in this step of the opera- 



THE RADICAL MASTOID OPERATION 



279 



tion, a gauze retractor is inserted in the membranous 
meatus. This is simply a strip of gauze which is passed 
into the depth of that part of the auditory meatus which 
is still attached to the auricle, starting from its anterior 
aspect, drawn out behind, and brought forward over 
the posterior surface of the auricle (see Fig. 88). The 
assistant makes gentle traction on this, thus exposing 
the depth of the osseous meatus. 



















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i 


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\ W^ 


1 




1 


m 


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1 1 


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Fig. 89. — Radical operation. The figure illustrates the first step in 
taking down the bridge. 

Forming and Taking Down the Bridge. — The author has 
found this step of the operation a difficult one for the 
student to understand from descriptions alone, but once 
performed upon the cadaver it becomes very plain. 
The upper and anterior part of the mastoid opening is 
now extended forward toward the zygoma. The distance 
to which this can be done depends altogether on the 
thickness of the superior wall of the canal. If there are 



280 OTITIS MEDIA PURULENTA CHRONICA 

cells or diploetic tissue between the cortex of this wall 
and the inner table (as in the specimen from which Fig. 
89 was made), the antral opening can be made to extend 
well forward even to the line of the anterior canal wall. 
This opens the vault of the tympanum and the bridge of 
bone between the canal and the upper cavity occupies 
an anteroposterior position. If, on the contrary, the 
floor of the middle fossa dips down, so that the cortex of 
the superior canal wall and the inner table exist in the 
same hard bone, and this of no great thickness, the bridge 
will be more or less vertical. The best instrument to 
remove this soft tissue between the cortex of the superior 
wall and the inner table is a small curette. It is inserted 
into the antrum (or vault as one works forward) and a 
small hold taken with the hollow of the bowl directed 
outward and forward, and by using the posterior margin 
of the bone wound as a fulcrum, made to travel outward; 
at the same time it is gradually rotated so that the back 
of the spoon is directed more and more toward the inner 
table, thereby preventing this structure from being 
removed and the dura thus exposed. As this work pro- 
gresses the outer end of the superior canal wall is taken 
down. 

The small gouge is used anteriorly and is directed 
parallel with the anterior canal wall and small shavings 
removed, working forward, thus lengthening the bridge, 
while with a small chisel shavings of bone are taken from 
behind forw^ard to meet the cut made with the gouge. 
It will be noticed that in using the chisel in this way it 
points toward the dura. It must therefore be under 
good control and be gently driven by the mallet and 
only to the cut in the bone already made by the gouge. 
Fig. 89 shows the cells and diploe removed and part of 
the superior canal wall taken down. It also shows why 
this partition between the two cavities is called a bridge. 
The bristles are passed from the vault into the atrium. 
This septa of bone forms an arch over the vault, its internal 
surface being a part of the outer wall of the vault. It is 



THE RADICAL MASTOID OPERATION 



281 



therefore a bridge, the posterior abutment of which is 
that part of the posterior tympanic wall adjacent to the 
additus ad antrum, while its anterior abutment is part 
of the anterior tympanic wall (superior wall if the bridge 
from anatomical conditions must be formed vertically). 
A curved probe passed from the antrum or upper cavity 
into the atrium, and pressed as far backward as possible 
against the posterior tympanic wall, lies upon the Fal- 




FiG. 90. — Radical operation. The bridge taken down, showing well- 
marked posterior overhang. 



lopian canal at about the junction of its tympanic with 
its third or descending part. This canal containing the 
facial nerve lies directly internal to the bend in the probe. 
Immediately above the facial lies the anterior half of the 
horizontal semicircular canal, which is now in plain 
view. On account of the nerve, in taking down the 
bridge it is desirable to work as far forward as possible. 
By using the gouge and chisel as above described, and 



282 OTITIS MEDIA PURULENT A CHRONICA 

taking a thin shaving at a time a V-shaped piece is removed 
from the bridge, the anterior arm of the A^ being as nearly 
level with and in the same direction as the anterior canal 
wall as possible, while the posterior arm slopes gradually 
across the bridge to meet the anterior arm at the apex of 
the V which is directed toward the tympanum. In taking 
out the last shavings, one must exercise great care that 
the instrument does not go through the bridge and 
impinge upon the internal tympanic wall, where it might 
do great damage. In all except the hardest bones, the 
curette may be used to complete this division of the bridge. 
It is inserted as in extending the antrum forward and 
rotated so that the cutting edge is in contact with tlie 
bridge well forward, then with increased pressure with 
its anterior hp it is withdrawn, at the same time scraping 
the upper surface of the l)ridge, that is, the surface toward 
the middle fossa. If, while pressing this instrument 
against the bridge, it goes through, no harm will be done. 
Thus the bridge is divided in such a manner as to leave 
a well-marked posterior overhang (Fig. 90). 

Removing the Overhang. — If there is an anterior over- 
hang it may be remoxed with a curette or small gouge. 
If the posterior overhang is quite long and there is no 
room to use the small curette between its point and the 
anterior wall, it may be shortened by chiseling off a few 
fine shavings. The remainder can be safely removed 
with the small curette, which is inserted internal to it 
with one cutting edge pressed against it (Fig. 91). By 
using the upper border of the bone wound as a fulcrum, 
the spoon of the curette is moved directly outward in 
the line of the external auditory canal. Only a little 
should be taken at a time and the probe should be used 
each time to determine the amount of overhang still 
remaining before an additional piece is taken. In remov- 
ing the last piece, the side of the curette is in contact 
with the bend in the Fallopian canal, and great pains 
should be taken not to allow the curette to rotate and 
thus produce pressure with the back or side of the bowl 



THE RADICAL MASTOID OPERATIOX 



283 



against this canal, as a depressed fracture of the Fallopian 
canal wall would be produced and facial paralysis result. 
In this work so close to the nerve, the anesthetist watches 
the face carefullv and should anv twitches be seen, imme- 




FiG. 91. — Method of using the curette in taking down the posterior 

overhang. 



diately reports the fact to the surgeon, so that having 
warning of the maneuver which disturbed the facial 
nerve and thus produced the twitches, he may not repeat 
it. The object in taking down the posterior overhang 
flush with the posterior tympanic wall is that if it is not 



284 OTITIS MEDIA PURULENTA CHRONICA 

done a cavity will be left which interferes with subse- 
quent healing or the taking of grafts if they are used. 
While removing the posterior overhang a dry field is 
necessary; therefore, as soon as there is sufficient exposure 
of the tympanum, the ossicles are taken out and granula- 
tions removed with a sharp ring curette, with flexible 
shaft, as from the latter troublesome bleeding often takes 
place. The wound should be packed with gauze saturated 
with adrenalin solution to arrest the hemorrhage and 
obtain a dry field. 

Lowering the Facial Ridge. — The ridge of bone which 
will now exist, partially dividing the cavity formed while 
opening the antrum from what remains of the osseous 
external auditory meatus, and known as the facial ridge 
or spur, is now to be taken down as far as possible with 
safety. For this purpose, the Richard curette is undoubt- 
edly the best and safest instrument, although a jjart of 
it may with safety be removed with the chisel. In lower- 
ing it, an attempt is made to enlarge the size of the 
opening leading to the tympanum. This is accomplished 
by scraping the facial spur on its external and anterior 
aspect. The horizontal semicircular canal is in plain view 
and is the guide to the position of the nerve. A line 
dropped from this canal directly downward, that is, 
parallel with the median line of the body, is supposed 
to be just without the facial nerve and theoretically one 
may remove this mass of bone to this line. In practice, 
however, one stops somewhat short of this, as instances 
are on record in which the nerve has occupied a position 
somewhat external to this line. The point at which the 
nerve is endangered, if it is at all, is near the semicircular 
canal. 

Lowering the Floor. — In some subjects the inferior wall 
of the external auditory meatus is high and its inner end, 
surmounted by the tympanic ring, causes a cavity to 
exist in the middle ear, the hypotympanum or cellar. 
If this condition is present, the floor must be lowered and 
the arc of the tympanic ring removed, so that the inferior 



THE RADICAL MASTOID OPERATIOX 285 

wall or floor will be made flush with the floor of the canal. 
The tympanic ring may be taken with the curette which 
is inserted internal to it and moved outward, thus scrap- 
ing this structure flush with the tympanum. The position 
of the jugular bulb beneath the floor of the middle ear, 
and in proximity to the end of the cmTtte while doing 
this work, must be borne in mind. For lower mg the 
inferior canal wall the gouge is used and shavings removed 
until it is sufficiently low. 

Eustachian Tube. — A small ciu-ette is inserted into the 
tympanic orifice of the Eustachian tube and the mucous 
membrane removed if possible to the isthmus. The 
carotid artery lies internal and adjacent to the tube, 
therefore all manipulations in this region should be made 
carefully. Insofar as possible, the cutting edges of the 
ciu^ette should be dhected outward and forward. The 
tympanic ring at the tubal margin may also be taken 
down. 

Cleaning the Cavity. — Tlii'ee important structures are 
to be borne in mind while cleaning the cavity. These 
are the facial nerve, the oval window with the stapes in 
position and the round window covered in by a thin 
membrane. If a sharp ring ciu^ette with flexible shaft 
is used to remove the granulations, mucous membrane 
and debris, these structiu^es will be safeguarded as far as it 
is possible to do so. Such an instrument glides over the 
Fallopian canal when a stift' ciu*ette of different shape 
would remove part of the wall, perhaps injiu-e the nerve 
also. Very little ciu^etting should be done in the region 
of the oval and round windows. ^Yith the ring curette 
the stapes, if in normal position, will escape injury. 
The author has never disturbed it in this manner but 
once. In this patient its foot-plate was necrosed and the 
ossicle lay in a mass of granulations (Fig. 78). The patient 
made a complete recovery, without untoward symptoms 
and with increased hearmg. In situations remote from 
these structiu-es a Spratt curette may be used to remove 
granulations, mucous membrane and carious areas of 



286 OTITIS MEDIA PURULENT A CHRONICA 

bone. The best operators devote much pains to this 
thorough cleaning of the cavity and much of the success 
of the operation depends upon its being done carefully 
and well. This is especially true if a primary skin graft 
is to be inserted. 

Meatal Flap. — The depth of the cavity is packed with 
gauze, which is saturated with adrenalin if it is to be 
grafted. The bleeding-points are tied and the hemostats 
removed. The gauze retractor is taken out and the sur- 
geon proceeds to form what is known as the meatal flap. 
The parts from which this is formed are the concha and 
the skin which Hned the external auditory canal and which 
was separated from this early in the operation. These 
parts constitute more or less of a membranous tube lined 
with the dermal epithelium. The object in cutting this 
flap is to open this tube and si)read it out on the walls of 
the radical cavity so that dermatization may l)egin from 
its epithelial margins, and at the same time to make a 
larger opening in the auricle through which the cavity 
can be taken care of during the healing process. 

A variety of methods have been devised for accom- 
plishing this purpose, some of which will l)e l)riefly noticed 
later. The flap advised as answering every i)urpose is 
the one devised by Ballance and slightly modified by Dr. 
Dench. Ballance si)lits the meatal tube through the 
middle of its posterior aspect and reflects the flaps in 
either direction, while Dench splits the tube along the 
lower part of its posterior asj)ect thereby having but one 
flap to reflect and that upward. The conchal incision 
is about the same in either method. It is this flap as thus 
modified that will be described. The narrow-bladed 
knife is inserted into the opening in the auricle correspond- 
ing to the external auditory meatus and passed through 
the tube until it emerges at its inner end, which is now 
posterior as the auricle is drawn forward, the flat of the 
blade being pressed against the inferior wall with the 
cutting edge backward. With a sawing motion, but with 
very sHght pressure in the direction of the cutting edge, 



THE RADICAL MASTOID OPERATION 287 

the tube is cut through until the blade enters the concha. 
This part of the procedure takes place with the operator 
watching the posterior aspect of the tube the greater 




Fig. 92. — First step in cutting the meatal flap. 




Fig. 93. — Second step in forming the meatal flap. 



288 OTITIS MEDIA PURULENT A CHRONICA 

part of the time, and is shown in Fig. 92. The auricle 
is now turned somewhat backward and by continuing 
the sawing motion a round or oval flap is fashioned out 
of the concha (Fig. 93). This should be about as large 
as the ear will permit. If its removal leaves the opening 
round or oval and the crus of the helix is not invaded, 




Fig. 94. — Meatal flap sutured in position. 

there will be no deformity. In making these incisions 
when the sinus or dura is exposed, great care should be 
exercised. It is a good plan to have the assistant cover 
them with some flat instrument, or a probe-pointed knife 
may be used after the incision is started. The ear is now 
held forward and the flap dra\\Ti out behind the auricle. 



THE RADICAL MASTOID OPERATION 289 

It will be found to consist of skin, cartilage and fibrous 
tissue. The dermal layer is carefully dissected from the 
other parts of the flap, which are then removed, taking 
care not to cut too deeply into the cartilaginous frame- 
work of the auricle. The skin is now sutured to the back 
of the auricle and tissues adjacent with chromicized 
catgut (Fig. 94). Care should be taken that the first 
suture is near the external end of the skin flap and that 
it draws it well up out of the meatus. Another suture is 
then placed more internally and the internal tip of the 
flap is applied to the superior surface of the radical cavity, 
being of course continuous with whatever integument 
has been left on the anterior canal wall. 

Other Flaps. — The Pause flap is T-shaped, the top of 
the T being placed vertically in the concha while the long 
arm splits the canal tube through the center of its pos- 
terior wall. The skin is dissected from the fibrous and 
cartilaginous tissues, which are removed, while the two 
skin flaps thus formed are sutured, the one upward, the 
other do^Tiward. Korner makes two incisions in the 
tube, the one above, the other below. By splitting the 
tube in this way its posterior surface forms a tongue 
attached at the concha. This is then sutured to the raw 
surface on the back of the auricle. Besides these there 
are various modifications of the Pause flap and others 
which, while ingenious, need not be described, as the 
one given above in detail will be found to answer all 
requirements. 

After-treatment. — Two modes of procedure from this 
point will be described, first, without a skin graft, and 
second, with a primary skin graft. The radical cavity 
is packed with iodoformized gauze, the end of which is 
brought out of the meatus. The posterior wound is com- 
pletely closed with clamps or silkworm-gut sutures and 
the dressing applied as in the simple mastoid operation. 
The wound is dressed through the meatus and the rules, 
during the first two weeks, for changing the gauze pack- 
ing, removal of the clamps, etc., are practically the same 
19 



290 OTITIS MEDIA PURULENTA CHRONICA 

as in the simple mastoid operation. After this, one must 
bear in mind that dermatization of the cavity is desired. 
Granulations may therefore be quite troublesome, as they 
interfere with this result. They should be kept down 
with the fused bead of nitrate of silver and the sharp 
ring curette. Some cavities do better with firm packing, 
others, if left open. Packing may interfere with the prog- 
ress of the dermatizing line, although it may keep the 
granulations down. Large granulations frequently form 
at the upper posterior angle of the meatus which must 
be removed with the curette and their bases cauterized 
with the fused silver bead. A small granulation in an 
otherwise normal cavity is capable of prockicing con- 
siderable discharge. Granulations may form on the 
internal tympanic wall and fill the cavity to a greater 
or less degree, then in this state the surface of the granu- 
lating mass may become dermatized. Naturally the fact 
that this pad of granulations exists over the oval and 
round windows interferes with hearing. At times this 
new-formed tissue will break down on account of its 
lowered vitality and leave a fairly good cavity with better 
hearing. These patients are discouraging to treat, as 
one may watch an unsatisfactory cavity developing 
from day to day and not seem to be able to do anything 
to prevent it. Still, many of them heal and become dry 
in from six to ten weeks, or the process of cure may take 
longer. 

Skin Graft. — It is to shorten the period of healing and 
to insure the formation of a proper cavity that the method 
of lining these cavities with skin grafts has been devised. 
This may be done either at the time of the operation 
(primary graft) or a week or more later (secondary graft) . 
If primary grafts are used, all bleeding-points are tied, 
the cavity packed with adrenalin gauze and pads placed 
over all upon which pressure is made while the grafts are 
being cut. It is absolutely necessary to have a dry cavity 
to insure success, and it is also safer. Epithelial grafts 
are cut from the thigh as thin and as large as possible. 



THE RADICAL MASTOID OPERATION 291 

This is done with the razor, which is specially designed 
for this purpose (Fig. 95). These are placed epithelial 
side upward on glass slides or metal plates and spread 
out with a needle (Fig. 96). The packing is now taken 
from the cavity, the graft moved to the end of the plate 
and caught at two points and held against the anterior 
wall of the cavity. The plate is now drawn backward, 
thus sliding from under the graft, which thus lies spread 




Fig. 95. — Razor for cutting epithelial grafts. 

out over the opening of the cavity. It is now tucked in 
sufficiently to bring its margins in contact with the upper 
and lower walls of the cavity. A pipette is now inserted 
between the graft and the inferior canal wall and passed 
until its tip reaches the internal tympanic wall. The 
graft is tucked around the pipette' so that the cavity 
beneath the graft becomes air-tight. The assistant now 
sucks upon the rubber attached to the pipette, drawing 
out the air and any secretion that has accumulated 



Fig. 96. — Teasing needle for Thiersch's grafting. 

beneath the graft. This sucks the graft into the cavity. 
While this is being done the anterior margin of the graft 
is held in contact with the anterior wall of the canal, 
that this part of the graft may not slip into the cavity 
and thus fail to cover the anterior wall which is bare 
internal to the end of its cutaneous covering. If this 
maneuver is successful, the graft becomes closely applied 
to the walls of the cavity. Small pledgets of cotton 



292 OTITIS MEDIA PURULENTA CHRONICA 

dusted with aristol are now applied against the graft; 
the first, with a black thread attached to facilitate removal, 
is placed well into the orifice of the Eustachian tube, and 
the remaining as the cavity may demand to hold the 
graft closely applied to its walls. Another graft may be 
applied to the raw posterior surface of the auricle and 
,brought out through the meatus. This will prevent 
troublesome granulations from forming at the margin 
of the conchal incision. Only that part of the posterior 
raw surface of the auricle should be covered that will, 
when the ear is sutured in position, overlie the radical 
cavity. If the graft lies between the flap and the surface 
of- the bone posterior to the cavity, it will interfere with 
healing of the posterior incision. The remaining part 
of the cavity is packed with sterile gauze, the end of which 
lies near the meatus and the posterior incision closed 
with clamps. The remainder of the dressing is the same 
as after the simple mastoidectomy. The thigh wound, 
from which the Thiersch grafts have been taken, is 
covered with silver foil and a dressing applied. 

After-treatment. — This operation completely lines the 
cavity with epithelium, and if the graft takes and there are 
no contraindications, the gauze and pledgets may remain 
for four days. The epithelium peels off a day or so later 
and leaves a dermatizing surface. The bandage should 
be left off as soon as the pledgets are removed. The clamps 
are removed from the posterior wound in two or three 
days; after four or five days, the dressing is held in place 
by painting with collodion. The cavity is to be irrigated 
with saline or bichloride, 1 to 10,000, every three to six 
hours, according to the amount of discharge. The cavity 
is wiped out daily with peroxide, one-half strength, dried, 
then alcohol applied, after which boracic acid may be 
insufflated. If the graft takes in part only, the granula- 
tions must be kept down to allow dermatization to pro- 
ceed. It is a bad plan, however, to pack these cavities, 
as the grafts may thus be destroyed. 

If complications arise during the first four days, it 



THE RADICAL MASTOID OPERATION 293 

may become necessary to remove the grafts, or at times 
the packing and pledgets may be taken out. This must 
be left to the individual judgment of the surgeon. If he 
believes that the grafts and the firm packing holding them 
in place are producing labyrinthitis, he will remove them 
just as he would redress a wound in which they are not 
present under the same circumstances. For the com- 
plications following the radical operation, the student 
is referred to Labyrinthitis, Meningitis and Sinus Throm- 
bosis. 

Posterior Openings. — At times, after a radical operation, 
the posterior wound becomes infected and breaks down. 
In this event it may become necessary to insert a gauze 
drain into the wound. This may be done temporarily, 
but it is a bad plan to continue the use of this posterior 
packing, as to do so results in the formation of a per- 
manent opening brought about by the inward growth of 
the epithelium from the margins of the wound. 

The proper procedure is to pack the cavity through 
the meatus, place a light dressing over but not into the 
posterior opening, then by applying a pad anterior to 
the auricle, the bandage is put on in such a manner as to 
force the ear upward and backward, thus approximating 
the margins of the posterior wound. By persisting in 
this treatment healing will occur without the opening 
becoming permanent. 

Occasionally one is called upon to close these posterior 
openings for the sake of the cosmetic effect. It then 
becomes necessary to perform a plastic operation. Several 
of these have been devised. The object is to form a 
flap which may be turned into the fistulous opening in 
such a manner that the epithelial side will become part 
of the lining of the radical cavity. To accomplish this 
a tongue of skin may be cut and reflected into the opening, 
its margins being held in place by sutures (Mosetig- 
Moorhof), or flaps may be formed on either side of the 
opening turned inward and held together with sutures 
(Passow-Trautmann), the raw surfaces being covered 



294 OTITIS MEDIA PURULENTA CHRONICA 

with flaps of integument or allowed to dermatize without 
them. A modification of these methods may be necessary 
to suit individual cases and may with safety be left to the 
ingenuity of the surgeon. 

Results. — ^A properly executed radical operation should 
result in a dry ear in about 70 per cent, of the patients, 
most of the other thirty should be nearly dry or only 
run at intervals, usually from tubal infection. Moreover, 
the danger to intracranial complications is practically 
eliminated. The mortality from the radical operation 
should not be much over 2 per cent., that is, when the 
operation is done for chronic suppuration alone. If it 
is a part of the surgical interference for a brain abscess 
or meningitis, and death results, it can in no way be 
attributed to the radical operation. 

In some patients the hearing is made worse by the 
operation, in others the hearing is not changed, while 
occasionally one sees a patient whose hearing is improved. 
As a rule the more acute the hearing before operation, 
the greater the danger that the patient will be deafer 
after it. Marked impairment of hearing is not so often 
changed for the worse. The uncertainty of prognosis 
as to the hearing makes it a rule in binaural suppuration 
that the worst ear should be operated on first, and the 
second ear should not be operated upon if it can possibly 
be avoided, unless the hearing in the operated ear becomes 
better than that in the other ear. 

MODIFIED RADICAL OPERATION. 

Indications. — Several modifications of the radical opera- 
tion are performed and advocated by different surgeons. 
The principal reason for them is the desire to preserve 
the hearing. It is claimed that by leaving the drum 
membrane and ossicles, the hearing will be much better 
than if these structures are removed. This may be 
conceded if their relations are not disturbed during the 
operation or their movements limited by subsequent 



MODIFIED RADICAL OPERATION 295 

formation of cicatricial tissue during the healing process. 
One is never certain that all of the diseased tissue has 
been removed, as so much of the cavity is not open to 
inspection. ^Moreover, for the operation to be at all 
better than the radical procedure, in regard to the con- 
servation of hearing, the drum membrane and ossicular 
chain must be of some value in the conduction of sound. 
]Many radical operations are done when this is not the 
case, these structures rather interfering with, than aiding 
in, sound conduction. While all diseased tissues may not 
be removed, the cavity, as usually formed, is so small 
that during the healing process it fills with granulations, 
troublesome to deal with and usually interfering with 
ultimate success. This modified procedure is indicated 
when one ear is very deaf and it becomes necessary to 
operate upon the opposite ear which possesses a fair 
amount of hearing. 

Operation. — The posterior incision and exposure of 
the canal are practically the same as in the radical opera- 
tion. The lining of the osseous canal usually tears near 
the membrana tympani so that the part of the canal 
adjacent to the tympanic ring which it is proposed to 
leave is not denuded of epithelium. The antrum is opened 
the same as in the radical operation, and its walls curetted 
and all granulations removed. The superior wall of the 
canal may be taken do^Ti except in proximity to Shrap- 
nell's membrane, where a substantial rim is left. The 
vault is opened by removing the cells, if present, between 
the cortex of the superior canal wall and the inner table. 
The vault is now cleared of granulations and diseased 
membrane as far as possible without injuring or displac- 
ing the ossicles. The posterior canal wall is taken dow^n 
except in the region adjacent to the tympanic ring. In 
fact, throughout the entire operation care is taken not 
to injure the drum membrane or ossicles. The meatal 
flap is cut and sutured in position as in the radical opera- 
tion. Skin grafts are not as a rule inserted. The auricle 
is sutured in position and the external end of the gauze 



296 OTITIS MEDIA PURULENT A CHRONICA 

which has been packed into the operation cavity is 
brought out through the meatus. This is changed in 
three or four days, and reinserted daily for a few dressings. 
Granulations are dealt with as in the radical operation 
without skin graft. If the operation is successful, the 
bone wound becomes dermatized and free from secretion. 
If this does not occur, the radical operation may be 
subsequently performed. 

OTITIS MEDIA PURULENTA RESIDUA (O. M. P. 
RESID.). 

Definition. — After a middle-ear suppuration has ex- 
hausted itself or been cured by non-operative treatment, 
certain changes are left or residual. These changes 
may be slight and interfere very little with the function 
of the organ of hearing or may be more marked and 
result in deafness or tinnitus. While these residual con- 
ditions are usually found as a result of chronic suppura- 
tions, they may also occur after the acute form. It 
seems best, therefore, to call them Otitis Media Purulenta 
Residua (O. M. P. Resid.), leaving out the w^ord chronica 
which has usually been inserted. 

Causation. — The condition is caused by suppuration 
of the middle ear, and whether or not changes will be 
left which will produce symptoms depends largely upon 
the intensity of the original process and the location and 
kind of these changes themselves. 

Pathology. — There is regularly more or less destruction 
of the membrana tympani, which has usually been 
repaired to the best of nature's ability by cicatricial tissue. 
If a small defect, this may be quite complete, the mem- 
brane regaining its motility and usefulness. In large 
perforations the membrane in healing usually becomes 
more or less adherent to the internal tympanic wall. 
Cicatricial bands and adhesions may be present that 
interfere with the motility of the ossicular chain, or the 
ossicles may have been destroyed by disease, in whole 



OTITIS MEDIA PURULENTA RESIDUA 297 

or in part.* In some instances the perforation fails to 
heal, but the ear continues dry. 

Symptoms. — ^The patients come complaining of deafness 
or of tinnitus or both. The deafness may be of a mild 
degree, the patient seeking relief for the head noises. 
Not infrequently the patient states that when his ears 
were discharging he heard better than since they were 
dry. This is usually found in patients with posterior 
defects in the drum membrane, and is explained by the 
fact that as long as the mucous membrane is moist it is 
pliable, but when it becomes dry and the fibrous tissue 
contracts, it becomes more rigid. This condition around 
the capitellum of the stapes, the ossicular chain or in the 
niche of the round window, would account for this symp- 
tom. The functional tests show the impairment of hear- 
ing to be due to lesion of the sound-conducting mech- 
anism unless the labyrinth is involved also. This 
occasionally occurs but cannot be considered as part 
of the process under discussion, although in a sense it 
may be residual, usually being a result of a labyrinthine 
inflammation. Changes in the lab^Tinthine capsule or 
inner ear described under Otosclerosis may occur in a 
residual ear and the tests would be modified accordingly. 
Less often a full feeling is a symptom. A patient recently 
observed complained of the snapping of the cicatricial mem- 
brane which had covered in the Eustachian tube, and he 
was continually swallowing to overcome the annoyance, 
being very anxious concerning the entotic noise. 

Otoscopic Appearance. — The changes in the membrana 
tympani are those which have been brought about by 
the exhausted suppuration. A perforation may exist 
which has failed to heal. The size and location of these 
perforations vary considerably, although they are usually 
not large. Their failure to cicatrize is brought about 
by the epithelium growing over the fibrous layer and 
meeting the mucous membrane, thus preventing the 
margins of the perforation from throwing out new tissue 
to close or contract the opening. Usually, however, the 



298 OTITIS MEDIA PURULENT A CHRONICA 

defect is closed by cicatricial tissue which is adherent to 
the internal tympanic wall, especially if the original per- 
foration was a large one. Where this tissue is formed on 
the inner wall of the middle ear, it is frequently covered 
with epithelium which presents a well-marked luster, 
not very unlike that of the membrana tympani. In large 
posterior defects that have thus healed, it is often possible 
to make out the landmarks on the inner tympanic wall, 
namely, the niche of the round window, the promontory, 
the oval window with the stapes in position, perhaps also 
the long process of the incus. The drum membrane 
anterior to these defects may be either cicatricial or the 
original membrane. The manubrium is very frequently 
adherent to the inner tympanic wall and may or may 
not be displaced or rotated. 

Diagnosis. — The diagnosis is made by the occurrence 
of impaired hearing or tinnitus, with the changes in the 
drum membrane which show an exhausted suppuration. 
Small perforations which have healed with cicatricial 
tissue may very closely resemble the depressed areas 
seen in O. M. C. C. The history will usually enable 
one to decide, but occasionally one sees drum membrane 
changes which could only have been produced by a for- 
mer suppurative process and be unable to obtain any 
history of such a process, it having occurred in infancy 
or childhood and therefore not having come to the patient's 
knowledge. When there is a perforation which has not 
closed and the ear remains dry, it may be considered as 
O. M. P. Resid. If, however, at intervals such a process 
is lighted up and discharges, the word ''residual" seems 
out of place. To call it a recurrent O. M. P. C. or an 
otitis media in a residual ear seems more reasonable. 

Prognosis. — ^The occurrence of O. M. P. Resid. may be 
regarded, in one respect, as fortunate, as it represents the 
healing of an active process. Nevertheless, the outlook 
as to much improvement of the hearing or relief from the 
noises cannot be regarded as very favorable. 

Treatment. — ^The treatment of a resolving purulent 
process of the middle ear with a view to minimizing 



OTITIS MEDIA PURULEXTA RESIDUA 299 

impairment of hearing, has aheady been discussed. If 
the perforation has been small and become healed, infla- 
tions sometimes have a favorable influence on the deaf- 
ness. With the view to improving the hearing, attempts 
have been made to bring about the healing of perforations 
which remain open. Probably the best method is by 
applying a paper splint by moistening a small piece of 
waxed paper and placing it over the opening in the 
membrane. In many instances this produces marked 
improvement of hearing at once. The parts should be 
inspected every few days to see that the paper is in posi- 
tion and that reactionary signs have not developed. If 
there is inflammation or discharge, the paper should be 
syringed from the ear, and this allowed to subside before 
reapplying the splint. 

In large perforations pneumomassage may be tried 
with prospect of slight improvement in the occasional 
patient. It is sometimes possible to increase the hearing 
by the insertion of a pledget of cotton. The absorbent 
cotton is wound upon an applicator in such a manner as 
to produce a fluffy end with a long stem, which is the 
part wrapped around the applicator. The pledget is 
slipped from the instrument and the fluffed end molded 
to the proper size. A few^ drops of liquid petrolatum 
are allowed to soak into the cotton, which is then inserted 
into the meatus by means of the stem. It is to be placed 
in contact with the inner tympanic wall in the region of 
the stapes and is intended to press upon this ossicle and 
conduct sonorous vibrations in an amplified form. 
Patients soon learn to introduce and remove these pled- 
gets of cotton and become very skilful in placing them 
in the exact position to improve the hearing, which it 
does at times to a remarkable degree. One would natu- 
rally suppose that the division of adhesions and bands 
which produce rigidity of the ossicular chain or interfere 
with the motility of the stapes would result in improve- 
ment of hearing, but operations in these patients have 
been disappointing, although occasionally of benefit. 



CHAPTER X. 

SUPPURATIVE DISEASES OF THE LABYRINTH. 

Under the heading of Suppurative Diseases of the 
Labyrinth are discussed those diseases of the labyrinth 
which are usually seen as complications of middle-ear 
processes of a suppurative nature. 

FUNCTIONAL TESTS OF THE STATIC LABYRINTH. 

Functional tests have already been described by means 
of which the condition of the acoustic labyrinth and its 
central connections may be determined. It now remains 
to describe certain tests, whereby one may derive informa- 
tion as to the condition of the static lal)yrinth. In doing 
this an effort will be made to divest the subject of much 
of its intricacy, and it is therefore necessary to avoid 
problems still unsettled as well as those which, while 
interesting in themselves, would tend to confuse the 
student. 

Physiology. — For all practical purposes, the cristse am- 
pullae are the end-organs of the vestibular nerve. While 
filaments of this nerve also end in the cristse of the vesti- 
bule, very little is known of their function. The cristae 
ampullae are little mounds of nerve tissue in the dilated 
ends of the three membranous semicircular canals, sur- 
mounted with hair-like processes which, projecting into 
the lumen of the canal, are influenced by movements of 
the endolymph contained in the membranous labyrinth. 
The nerve fibers from these cristae are connected with 
the vestibular nuclei in the medulla and mainly through 
them with the cerebellum, a spinal nucleus and with the 
motor oculi nucleus situated in the floor of the aque- 



FUNCTIONAL TESTS OF STATIC LABYRINTH 301 

duct of Silvius. Impulses arising in the cristae produce 
movement of the eyes through the latter connection. 
The motor oculi nucleus enervates the eye muscles, and 
the connection is so formed that muscles which move the 
eyes in a given direction receive their enervation from 
the same part of the nucleus. For example: the internal 
rectus of one eye and the external rectus of the other eye 
are enervated from the same part of the same nucleus. 
(Fig. 97). To move the eyes to the left the internal rectus 
of the right eye and the external rectus of the left eye 
contract and the stimulus comes from the right motor 
oculi nucleus. Now, if the right nucleus is stimulated by 




NERVE 
CENTERS 



NERVE 
CENTERS 

Fig. 97. — Diagram illustrating the origin of the eye muscles. 



impulses received through the connecting fibers between 
it and the cristse ampullae it produces movement of the 
eyes to the left. This movement takes place without 
volition, being simple a result of the stimulation of the 
cristae. As soon as the subject becomes conscious of this 
involuntary movement of the eyes to the left, which he 
does by the apparent movement of objects to the right, 
by an effort of the higher centers he brings the eyes 
back to the normal position! The movement toward the 
left produced by the vestibular irritation is slow, the 
movement to the right caused bj^ impulses emanating 
from the higher centers is a rapid one. A succession of 



302 SUPPURATIVE DISEASES OF LABYRINTH 

these to-and-fro movements is called nystagmus, and as it 
is due to stimulation received from the vestibular nucleus 
it is called vestibular nystagmus. It differs from ocular 
nystagmus, that is, nystagmus due to disease of the eyes, 
as well as almost all other forms of nystagmus, in that in 
vestibular nystagmus there is a slow movement in one 
direction and a rapid movement in the ()pi)osite direction, 
that is, a slow component and a rapid component. It may 
be produced by disease of the static labyrinth or the 
cerebellum, although the latter is not as typical as the 
former. When caused by disease it is called spontaneous 
nystagmus. It may also be ])roduced by certain experi- 
ments to which the ])atient may be subjected and is then 
known as experimental or induced nystagmus. In the 
normal patient it may be experimentally induced in three 
ways, namely: (1) by rotating tlie patient; (2) by 
syringing the ear with hot or cold water; (.*}) by the gal- 
vanic current. 

Ewahrs Laws. — In order to understand either rotation 
or caloric nystagmus and be able to predict the form and 
direction of the eye movements which will follow any 
rotation or syringing, Ewald's experiments and the rules 
derived from them must be thoroughly imderstood. 
Ewald drilled a small hole in the semicircular canal of 
pigeons, and attached a delicate tube connecting with a 
rubber bulb (Fig. 98). The end of the canal away from the 
ampulla he plugged with lead. It will readily be seen that 
pressure upon the bulb would produce a current in the 
canal toward the ampulla, while relaxation of the bulb 
would produce a current away from the ampulla, that is, 
canalward. When this apparatus was attached to the 
horizontal semicircular canal and the bulb compressed 
and a current toward the ampulla produced, the pigeon 
turned its head and eyes to the opposite side. When 
the pressure was relaxed and the current reversed, that 
is, canalward from the ampulla, the head and eyes moved 
to the same side but less strongly. To state this in the 
form of a law: (1) In the horizontal semicircular canal 



FUNCTIONAL TESTS OF STATIC LABYRINTH 303 

when the current is from the canal toward the amjmUa, the 
crista becomes phis (+). In like manner the superior semi- 
circular canal was experimented upon but, unlike the 
horizontal, the greater movement occurred when the 
current was away from the ampulla, that is, canal ward. 
(2) In the superior semicircular canal when the current 
is from the ampulla toward the canal, the crista becomes 
plus. The posterior is the same as the superior. 



CRISTA /T 

ampullae: 




LEAD^- RUBBER BULB 

PLUG 

Fig. 98. — Ewald's experiment. 

Rotation Nystagmus. — By rotation, currents in the semi- 
circular canals may be produced in man, and by observing 
the ensuing reactions a conception of the condition of the 
static labyrinth may be formed. The patient is placed 
in a chair capable of rotation. When he is seated with 
head erect, it is evident that the horizontal canals lie, 
approximateh', in the plane of rotation. He is now rotated 
ten times. At the beginning of rotation the endolymph 
in the horizontal semicircular canals, by reason of its 
inertia, lags behind. This has the effect of producing a 
current opposite to the direction of rotation. This 
produces a nystagmus which follows the rules to be men- 
tioned, and has been seen by an observer occupying a 
platform which rotated with the patient, thus allowing a 
view of the eyes to be obtained during the rotation. But 



304 SUPPURATIVE DISEASES OF LABYRINTH 

this method is impracticable, therefore not used. After 
the patient has been rotated ten times, the endolymph has 
picked up the motion of the horizontal canals and is 
moving at the same rate and in the same direction as the 
canals and there is therefore no current. The rotation 
is now suddenly stopped and the canal becomes at rest, 
but the endolymph on account of its inertia continues in 
motion. This produces a current in the direction of rota- 
tion. As the ampulla of the horizontal canals lies anteriorly 
it follows that the current will be toward the ampulla 
in one and away from the ampulla in the other (Fig. 99). 
While the current in the two canals, the one plus and the 
other minus, have the same effect upon the eyes, since the 





HORIZON TAL 
CANALS 

Fig. 99. — Diagram illustrating an inertia current in the horizontal 
semicircular canals. 

impulse from the minus current is added to and augments 
the reactions arising from the plus current on the opposite 
side, it is best in figuring the reactions to think only 
of the crista which is plus. Thus in turning from left to 
right, as in Fig. 99, the movement of the fluid after rotation 
in the left canal is toward the ampulla, and as the head 
is erect this must be the horizontal canal and it is therefore 
plus according to rule (1). By completing the diagram 
(Fig. 100), it will be seen that a stimulus goes to the central 
nuclei of the vestibular nerve from the crista of the left 
semicircular canal; thence to the motor oculi nucleus on 
the left side. In this nucleus an impulse is aroused which 
produces contraction of the internal rectus on the left 



FUNCTIONAL TESTS OF STATIC LABYRINTH 305 

side and the external rectus on the right side. This turns 
the eyes to the right. But the higher centers send out an 
impulse to the opposing muscles which, with a quick move- 
ment, bring the eyes back to their normal position, that 
is, the quick component is to the left. This sequence of 
events is repeated again and again during from twenty to 



RAPID 




Fig. 100. — Diagram for rotation to right with head erect = horizontal 
after nystagmus to the left. 



thirty seconds in the normal labyrinth. The result of the 
experiment is horizontal nystagmus to the left after 
rotating the patient to the right. Without entering into 
a discussion as to the exact origin of the impulse producing 
the quick component, it may be stated that it does not 
take place under anesthesia or when for any reason 
20 



306 SUPPURATIVE DISEASES OF LABYRINTH 

the patient is unconscious. Nystagmus is arbitrarily 
named from its quick component. Thus the nystagmus 
in the above experiment is called to the left as the quick 
component is to the left, the slow being to the right. 
A nystagmus is always intensified by having the patient 
look in the direction of its quick component. Therefore, 



RAPID 




Fig. 101.— Diagram for rotation to left with head erect = horizontal 
after nystagmus to right. 



in eliciting this nystagmus, the patient would be directed 
to look at the finger held as far to the left as possible 
without causing the bridge of the nose to interfere with 
the view of the right eye. In determining the direction 
in which one is rotating a patient, one must think of the 
patient's face. For instance, if the patient's left eye is 



FUNCTIONAL TESTS OF STATIC LABYRINTH 307 

following his right eye, he is being rotated to the right 
and vice versa. 

Suppose the patient be rotated to the left with head 
erect. The diagram is shown in Fig. 101. The right eye 
follows the left eye diu^ing rotation. At the end of ten 
revolutions and after the head is at rest, the endolymph 
current is in the direction of rotation, as shown by barbed 
arrow. That is, toward the ampulla in right horizontal 
canal which thus becomes +; right centers +; internal 
rectus of right eye and external rectus of left eye +. 
Slow movement of eyes, shown by plain arrow to left; 
quick movement shown by barbed arrow to the right 
= horizontal after nystagmus to the right produced by 
rotating patient with head erect to the left. 

Suppose the head be bent forward 90 degrees and the 
patient rotated to the right. This brings the superior 
canals into the plane of rotation. This statement is not 
strictly correct, as the superior semicircular canals are 
at an angle of about 45 degrees with the coronal plane. 
Still, as both of their ampullated extremities are situated 
externally, the current of endolymph which is produced 
by rotation is practically the same as though they were 
in the coronal plane. The nystagmus produced by rota- 
tion with the head forward 90 degrees is rotatory. The law 
determining the form of nystagmus is that the eye move- 
ments will be in that meridian in which the horizontal 
plane cuts the cornea during rotation. Thus, with the 
head erect the horizontal plane cuts the cornea perpendic- 
ular to the median line and rotation produces horizontal 
nystagmus; with the head bent forward or backward 
90 degrees, the horizontal plane cuts the periphery of the 
cornea and rotation produces rotatory nystagmus; while 
with the head 90 degrees to one side the horizontal plane 
cuts the cornea in the sagittal plane and rotation produces 
vertical nystagmus. The law also holds true in inter- 
mediate positions of the head. 

It is evident that the eye muscles which produce 
rotatory nystagmus are not the same as those which 



308 SUPPURATIVE DISEASES OF LABYRINTH 

produce the horizontal form; nevertheless, the diagram, 
although perhaps slightly inexact, will work out to a 
correct conclusion without involving one in more diffi- 
culties. Rotatory nystagmus is named from the direction 
of the quick component of the upper end of the vertical 
meridian of the cornea. See Fig. 102, which shows 
rotatory nystagmus to the right, the upper pole of the 
vertical meridian having a quick movement toward the 
patient's right, the slow component being to the patient's 
left. With the head forward the ampulhi of the superior 
semicircular canals become ])()sterior as well as external. 
Drawing the diagram (Fig. 10')) » il the i)atient is rotated 
to the right, current at the end of rotation to the right, 




ROTATORY NYSTAGMUS TO RIGHT 

Fig. 102. — Diagniin illustni(iii« tho (letenninutioii of the direction of 
rotatory nystagmus. 



that is, toward tlie am])ulla in tlie right canal and away 
from the ami)una in the left. Left crista +, according to 
Ewald's law (No. 2), left centers +, muscles which rotate 
the upper pole of the cornea to the right +, therefore, 
slow component to the right; rapid component to the 
left =. Rotatory nystagmus to the left produced by 
rotating the patient with the head forward 90 degrees 
to the right. 

Suppose the patient with head backward 90 degrees 
is rotated to the right. The ampulla of the superior 
semicircular canals which are below and external with 
the head erect are thus brought to an anterior and external 
position and the crista? are therefore stimulated bv the 



FUNCTIONAL TESTS OF STATIC LABYRINTH 309 

current produced by rotation, which is toward the ampulla 
in the left canal (Fig. 104). Right crista +, right centers 
+ , slow component to the left, rapid component to the 
right = . Rotatory nystagmus to the right produced by 
rotating the patient to the right with head backward 



RAPID 




Fig. 103. — Diagram for rotation to right with head forward 90° = rota- 
tary after nystagmus to left. 



90 degrees. It is only iiecessary to remember Ewald's 
laws which are founded on physiological facts. They 
are true but no reason can be given why nature has 
designed these canals in exactly this way. By drawing 
his diagram, the student should now be able to figure 
out the effect of any given rotation. 



310 SUPPURATIVE DISEASES OF LABYRINTH 

Caloric Test. — In the rotation experiments the current 
is produced by the inertia of the endolymph. In the 
caloric tests a gravity current is produced by means of 
heat or cold. With the head erect the superior semicircular 
canal is above the vestibule (Fig. 105). If, therefore, 

RAPID 




Fig. 104. — Diagram for rotation to right with head backward 90° = 
rotatory nystagmus to right. 



a stream of cold water, say at a temperature of 50° F., 
is directed against the membrana tympani, the air in 
the tympanic cavity becomes colder and this change of 
temperature is communicated to the vestibular fluid 
adjacent to the internal tympanic wall. It thus becomes 
condensed, and gravitating, produces a current downward. 



FUNCTIONAL TESTS OF STATIC LABYRINTH 311 

This draws fluid from the superior semicircular canal, 
producing a current toward the ampulla as shown in 
Fig. 105. iVccording to Ewald's law, this makes the 
canal minus. The opposite crista would therefore be 
plus, as normally the stimuli emanating from the opposite 
labyrinths are exactly balanced and this syringing with 
cold water creates an imbalance or disharmony. 

Suppose the right ear be syringed with cold water, 
with head erect (Fig. 106). This produces a current 



CAa/ 




Fig. 105. — The method of the production of the gravity current. 



toward the ampulla in the right superior canal. Right 
canal — , left canal +, left centers +. Slow component 
to the right, rapid component to the left = rotatory 
nystagmus to the left produced by syringing the right ear 
with cold water with the head erect. 

Suppose the right ear be syringed with hot water. 
This usually produces less effect than cold, as it is impos- 
sible to use water as many degrees above the normal 
temperature of the labyrinthine fluid as can be used 
below with cold water. Thus, water at a temperature 



312 SUPPURATIVE DISEASES OF LABYRINTH 

of 50° F. will produce more effect, other conditions being 
the same, than water at 115° F., the difference being as 
49 to 16, which is the amount these temperatures vary 
from the temperature of the labyrinthine fluid, say 99° 
F. As the hot water flows into the meatus it raises the 
temperature of the labyrinthine fluid adjacent to the 



/xP»C> 




?55i^l^. \ 




Fig. 106. — Diagram for syringing the right car with cold water, head 
erect = rotatory nystagmus to left. 



internal tympanic wall, and it being of a less specific 
gravity, rises into the superior semicircular canal, produc- 
ing a current away from the ampulla, that is, toward the 
canal (Fig. 107). Right crista +, right centers +, slow 
component to the left, rapid component to the right = 
rotatory nystagmus to the right produced by syringing 



FUNCTIONAL TESTS OF STATIC LABYRINTH 313 

the right ear with hot water. Let the student draw his 
diagrams and work out the result of syringing the left 
ear with hot or cold water and when the body is inverted 
with head downward. 



f?APID 




WATER 



Fig. 107. — Diagram for syringing the right ear with hot water with head 
erect = rotatory nystagmus to right. 



If the patient lies in the recumbent posture with the 
head backward at an angle of 60 degrees with the vertical 
plane, in which position the horizontal semicircular 
canal is most favorably situated to be stimulated by a 
gravity current, as it then becomes vertical, its ampulla 
being at its upper extremity, syringing with cold water 
produces a current away from the ampulla and the canal 



314 SUPPURATIVE DISEASES OF LABYRINTH 

becomes minus. Suppose the right ear be syringed 
with cold water (Fig. 108). Current away from the 
ampulla in right canal, right crista — , left crista + , left 
centers +, slow component to the right, rapid component 
to the left = horizontal nystagmus to the left produced 
by syringing the right ear with cold water with the head 

^ RAPID 



SLOW 



^ 




Fig. 108. — Diagram for syringing the right car with cold water, head 
backward 60 degrees = horizontal nystagmus to left. 



backward at an angle of 60 degrees. Let the student 
figure the reactions which would occur if, in this position, 
the right ear is syringed with hot water or the left ear 
syringed with hot or cold water. 

When the ear has been syringed with hot or cold water 
and nystagmus produced, if, during the continuance 



FUNCTIONAL TESTS OF STATIC LABYRINTH 315 

of the eye movements, the position of head is changed, 
the nystagmus is also changed. For instance, with the 
head in the optimum position for stimulation of the 
horizontal semicircular canal, that is, with the head 
backward at an angle of CO degrees with the vertical 
plane, the right ear is syringed with cold water and there 
results a horizontal nystagmus to the left as in Fig. 108. 
If now the head is changed to the vertical position and 
tipped slightly to the right, that is, the optimum position 
for stimulation of the right superior canal, the gravity 
current will affect the crista in the superior semicircular 
canal, the current being toward the crista, from the 
canal, as in Fig. 106, and there is produced a rotatory 
nystagmus to the left. The nystagmus has "been changed 
from horizontal to rotatory by changing the position of 
the head. This has been caused by change in the crista 
stimulated and is an argument in favor of the theory 
that the nystagmus persists only during the continuance 
of the endolymph current. 

Galvanic Test.— The induction of nystagmus by the 
galvanic current offers no special advantage over the 
rotation or caloric tests, nor is it as generally employed. 
Galvanism produces a combined rotatory and horizontal 
nystagmus which shows that all of the cristse, perhaps the 
nerve as well, are acted upon. No amount of pains has 
enabled the stimulation to be limited to one canal, to the 
exclusion of others. In patients from whom the labyrinth 
has been removed, if the vestibular nerve has not degen- 
erated, nystagmus may still be produced. The nystag- 
mus is in the direction of the current. For instance, if 
the cathode is applied at the right, and the anode at the 
left ear, the nystagmus will be to the right as the current 
is from the anode to the cathode. In this experiment 
a current of about 4 ma. will produce nystagmus. It 
will be noticed that in passing through the head both 
labyrinths and nerves are acted upon, and made in this 
way the galvanic test resembles the rotation test which 
also acts upon both labyrinths. 



316 SUPPURATIVE DISEASES OF LABYRINTH 

The anode may be held in the hand or placed elsewhere 
upon the body and the cathode placed before or back of 
the auricle. This will produce nystagmus toward the 
side to which the cathode is applied. A stronger current 
will be required. This acts upon one labyrinth alone, 
and in this respect resembles the caloric test, although 
unlike this test the canals cannot be separated. The 
degree of irritability is shown by the amount of current 
required to produce nystagmus. If the cathode is divided 
and one-half placed at either ear, no nystagmus is pro- 
duced if both labyrinths are alike in their irritability, the 
stimulation of one being equal to and opposite in effect 
to the stimulation of the other. 

Fistula Test. — The fistula test should l)e active only 
in an ear in which there is a defect in the labyrinthine 
capsule, although occasionally there is some response 
to this test in an ear not thus diseased. The test is made 
by inserting the tip of a PoHtzer air-bag into the meatus 
and compressing and relaxing it, or if there is a mastoid 
wound, a Bier's cuj) to cover all. This increase of 
pressure would act ui)()n a fistula by compressing the 
membranous labyrinth and producing a current in the 
endolymph. ]\Iore often than in any other situation, 
there is a fistula in the horizontal semicircular canal. 
Compressing and rarefying the air would act very much 
as in Ewald's experiments. On comi)ressing the bulb 
the force would act ui)on the membranous canal, the 
lumen of which would thus become narrowed and an 
endoljinph current toward the ampulla i)roduced. On 
relaxing the pressure the current would be in the opposite 
direction. The nystagmus produced by the fistula test 
is not continuous. The regular reaction is that on com- 
pressing the bulb the eyes are directed to the opposite 
side and brought back with a quick motion. On relaxing 
the bulb the slow movement less in degree is to the side 
experimented upon, while the quick movement is to the 
opposite side. This is considered the regular reaction, 
and if the test is positive, is more often present than any 



FUNCTIONAL TESTS OF STATIC LABYRINTH 317 

other; but there are various other reactions present at 
times. If upon compressing or relaxing the bulb there 
are any involuntary movements of the eyes, slow in nature, 
which are corrected by opposing quick movements, it 
is safe to say that the fistula test is positive. 

Value of Tests. — The object of the various tests is to 
determine whether or not a given labyrinth is active, and 
if possible the degree of its activity. In performing the 
rotation test with head erect and taking the time from 
the instant the rotation is stopped until the nystagmus 
ceases, the usual time in the normal person is between 
20 and 30 seconds, depending somewhat upon the rapidity 
of the rotation. If, after the two rotations in opposite 
directions, the nystagmus is about the same and between 
20 and 30 seconds' duration, it is assumed that both laby- 
rinths are equal and functionating. If instead of being 
equal the duration of the nystagmus in one should be, 
for instance, 20 seconds, while in the other it was less 
than 10 seconds, it w^ould be reasonable to suspect that 
one was not functionating; then this patient should be 
tested with his head forward or backward so that the 
inertia current would act upon the superior semicircular 
canals, and if a marked disparity, say of over one-half, 
in the two sides w^as shown, one's suspicion would be 
increased that one side was not functionating. The 
rotation test fo!* that lab\Tinth would be negative. If, 
upon rotation, the duration of the after-nystagmus in 
either direction Vvas about equal but much less than 
normal, for instance, between eight and twelve seconds, 
one would suspect that one labyrinth was dead and that 
compensation had occurred. Whether or not this was the 
case might be determined by the caloric test. 

Compensation, — When there exists an endolymph cur- 
rent toward the ampulla in the horizontal semicircular 
canal, for example, an impulse is produced which, trans- 
mitted to the central ganglia, causes certain results, 
among others nystagmus, and the crista is considered to 
be plus or in the positive phase. If the current is reversed. 



318 SUPPURATIVE DISEASES OF LABYRINTH 

that is, canalward from the ampulla, the effect on the 
eyes is the same but opposite in direction and about 
one-half as strong. The crista would then be minus or 
in the negative phase. The negative phase of one crista 
is in effect the same as the positive phase of the opposite 
crista and about one-half as much. This is true of all 
the cristse and therefore of the static labyrinth as a whole. 
Now, if one labyrinth is destroyed by disease or operation 
in such a manner that the cristie are also destroyed, the 
negative phase of the active labyrinth increases or its 
positive phase (Hminishes in force until a balance is pro- 
duced, the one labyrinth thus acting in a fairly efficient 
manner for both. In rotating a patient who has com- 
pensation l)ut one labyrinth is influenced by the currents 
produced, the other being in such a condition that cur- 
rents cannot be ])r()duce(l, but the reactions are the same 
in kind, as though both labyrinths were active but differ 
in degree. One would hesitate to consider compensation 
present if the duration of the after-nystagmus, with head 
erect, was over fifteen seconds. After the destruction of 
one labyrinth by disease or oi)erati()n some patients 
develop c()m])ensati()n; others do not in the sense in which 
the term is here used. It seems that some condition is 
necessary in the destroyed labyrinth in order that it 
should take place. Kuttin believes that this lies in the 
cristfe. If they are destroyed by operation or by the 
formation of bone or fibrous tissue in a latent suppurative 
process, then compensation will take place. Tntil further 
light is thrown upon the subject, the author is prepared 
to accept this as true. 

Caloric Test. — The caloric test has the advantage of 
being used upon one ear alone. It settles positively 
whether the labyrinth under examination can react to 
gravity currents produced by local change in tempera- 
ture of the labyrinthine fluid. About the only condition 
in which doubt may be felt is in patients who already have 
spontaneous nystagmus. For instance, a patient has a 
spontaneous nystagmus to the left and it is desired to 



FUNCTIONAL TESTS OF STATIC LABYRINTH 319 

ascertain whether or not the right ear is capable of respond- 
ing to caloric stimulation. The right ear mav be syringed 
with cold water and it may be noted whether or not the 
nystagmus is increased, or the ear may be s\Tinged with 
hot water to ascertain whether the nystagmus to the left 
is diminished or one produced to the right. One may 
still be in doubt after trying both of these plans. As an 
aid in such a case a fixator has been devised. This is 




Fig. 109. — Barany fixator (Kerrison) with author's permission. 



merely a head band to which a rod is attached in such a 
manner that it ma}^ be moved as desired (Fig. 109). 
At the end of the rod is an object upon which the patient 
fixes the eyes. The rod is moved until such a position is 
obtained that there is no nystagmus. The ear is then 
s\Tinged, and if nystagmus is produced, the caloric test is 
positive. 

Attempts to form a conception of the degree of irri- 
tability of the labyrinth by the caloric test are disap- 



320 SUPPURATIVE DISEASES OF LABYRINTH 

pointing. It is necessary to determine how much water 
at a given temperature, flowing through what length of 
time, is necessary to produce nystagmus in the normal 
labyrinth. When this is determined a variation is not 
necessarily due to a difference in the irritability of the 
labyrinth as many conditions, outside of the labyrinth, 
may exist to cause the reaction to be early or late in 
appearing. Thus the nystagmus comes on quickly with 
exposed inner tympanic wall covered with thin mucous 
mem})rane or skin graft. On the other hand, if it is cov- 
ered with granulations, polypi or a thick bed of cicatricial 
tissue, the nystagmus is slow in ai)j)earing. The same 
result is produced by stenosis of the external auditory 
canal. So, while one, after noting the conditions and the 
time of the aj)pearance of the nystagmus, may reasonal)ly 
infer in certain instances that the labyrinth is sluggish 
or abnormally active in its response to caloric stimulation, 
the attemi)t to accurately determine the degree of increase 
or decrease is not ai)t to be of much clinical value. Those 
desiring to pursue the subject further are referred to 
Briinnings^ and Kai)r()ff.''^ 

CIRCUMSCRIBED LABYRINTHITIS. 

Causation. — It is usually produced by chronic sui)pura- 
tive processes, especially cholesteatoma, although it may 
occur in an early stage of a tubercular otitis media. 

Pathology. — Circumscribed labyrinthitis, as at present 
conceived, is a localized sequestration or erosion of the 
labyrinthine capsule which results in the formation of 
an osseous defect. The horizontal semicircular canal is 
the one usually involved, as it seems by its exposed situa- 
tion to be favorably located to be affected by middle-ear 
processes, although the other canals are at times involved. 
The semicircular canals seem peculiarly fitted by their 

1 Verhand. der Deutsch. Otol. Gessel., 1910, and Zeitsch. fiir Ohron- 
heilk., 1911. 

2 Passow's Beitrag., vol. ii, p. 190. 



CIRCUMSCRIBED LABYRINTHITIS 321 

anatomical construction to be the seat of circumscribed 
inflammation. When a bony defect is found in other 
parts of the lab^Tinthine capsule, for instance, the 
promontory, it is the rule to find the labyrinth generally 
involved, although there are at times exceptions. The 
process may be limited to the bony capsule or there may 
be a localized membranous lab^Tinthitis. 

Symptoms. — The disease may have presented symptoms 
or be found at the radical operation not having been 
previously suspected. This is more probable to occur 
if the surgeon is not in the habit of having fistula tests 
made on all patients before operation. When symptoms 
are present, vertigo is usually one of them. It is usually 
of mild type but may be more severe and occur in attacks 
during which there is nausea and vomiting. It may be 
increased or brought on by sudden changes in position 
of the head, as in stooping or turning around suddenly. 
Exceptionally, a severe form of vertigo may occur, but 
in this event one suspects that a serous lab^Tinthitis 
may be present. There is usually nystagmus directed 
either toward the involved side or to both sides. It may, 
however, be absent. It is not as a rule marked, usually 
being seen in lateral positions of the eyes. It is usually 
a combination of the horizontal and rotatory types. The 
hearing is not as a rule affected, any deafness which may 
be present showing tests of involvement of the conduct- 
ing mechanism. Exceptionally, when the attacks of 
vertigo are present, the hearing is diminished from 
involvement of the perceptive mechanism. One may 
speculate on the cause of this, but very little is known. 

Tests. — Upon applying the tests if the patient has this 
form of labyrinthitis and no other, there will be found: 
hearing present, rotation positive, caloric positive, fistula 
test positive. ]\Iany place very little reliance upon the 
fistula test, claiming that some response is made to it in 
the normal condition owing to the disturbance of the 
structures in the oval and round windows caused by the 
change in air pressure, the test thus being positive without 
21 



322 SUPPURATIVE DISEASES OF LABYRINTH 

a fistula, while the conditions may be such in the region 
of a defect in the labyrinthine capsule that the change in 
pressure, used in making the test, would not be com- 
municated to the labyrinthine fluid. All of this may be 
to a certain extent true; nevertheless, the fact remains 
that as a rule it is positive in fistuhe and should it occa- 
sionally appear to be ])()sitive in the absence of a fistula, 
the test is still of vahie as showing that the labyrinth 
possesses irritability. 

Diagnosis. — Should a patient with a suppurative pro- 
cess in the middle ear have vertigo mild in degree, nystag- 
mus to the same or to both sides in lateral positions of 
the eyes, and hearing not j)r()f()un(lly aliVctcd, j)resent a 
positive rotation, caloric and fistula tests, one would 
reasonably expect to find at ojKTation a fistula in some 
part of the labyrinthine capsule and would no doubt be 
able to find it. 

Prognosis. — A fistula may heal after the cause ])ro(lu('ing 
it has been removed or it may result in a serous or purulent 
labyrinthitis. This may occur either before or after 
operation, for the middle-ear process of which it was a 
complication. 

Treatment. — These fistula*, when found at operation, 
are to be let alone. A secpiestrum, if ])resent, may be 
removed. If granulations are exuberant, one may no 
doubt justify oneself if he carefully curettes them. How- 
ever, the barriers between the sui)i)uration and the 
healthy labyrinth must be conserved; therefore no 
meddlesome probing or other manipulation is justifiable, 
nor can a primary graft be used. After operation the 
patient is to be watched carefully for extension of the 
process to the hitherto uninvolved labyrinth, that proper 
measures may be promptly undertaken should it occur. 

SEROUS LABYRINTHITIS. 

Serous labyrinthitis may result from the circumscribed 
form — secondarv serous labvrinthitis — or it mav follow 



SEROUS LABYRINTHITIS 323 

the radical operation or suppurative middle-ear processes 
— induced serous labyrinthitis. 

Pathology. — A suppurative process either at the site 
of a fistula or in the recesses of the oval or round windows 
seems sufficient to cause a serous or serofibrinous laby- 
rinthitis. The bacteria proliferating at the oval and 
round windows cause swelling and infiltration of the 
tissues with a fibrinous deposit on the internal surface 
of the membrana tympani secoudaria and the annular 
ligament of the stapes. There is a dilatation of the laby- 
rinthine bloodvessels and increase in the amount of peri- 
lymph. The pressure caused by increase of perilymph 
produces various distortions, and adhesions may form 
making resolution wath restoration to normal function 
impossible. The utricle and saccule may be compressed 
and the ductus cochlear is distorted. This tube may be 
collapsed at the apex and dilated at the basal whorl or 
from increase in endolymph dilated throughout. These 
changes in the cochlear duct or scala media, containing 
as it does the organ of Corti, naturally result in profound 
impairment of hearing. Round cells are found in the 
labyrinth but no bacteria; once these appear on the 
inner surface of the structures closing the oval and round 
windows the disease very rapidly becomes purulent. 
In not all patients are the changes in structure so pro- 
found, for return of hearing at times occurs to nearly 
the condition present before the development of the 
disease. 

Symptoms. — The onset of the symptoms is usually 
quite sudden. The patient experiences marked vertigo 
accompanied by nausea and vomiting. There is nystag- 
mus to the side away from the disease. This may be 
proceeded by nystagmus to the diseased side, but this 
is not often observed, as it usually disappears with the 
onset of the symptoms of ''destruction disharmony" — 
vertigo, nausea and vomiting, nystagmus to the healthy 
side. These are brought about by the sudden cutting 



324 SUPPURATIVE DISEASES OF LABYRINTH 

out of the impulses which normally emanated from the 
involved labyrinth. The lab\Tinth ceases to functionate 
and an imbalance or disharmony is produced. One 
could understand this better if he assumed that the 
imbalance was between the two labyrinths alone; but 
experiments have demonstrated that the condition is by 
no means so simple, as these phenomena take place in 
animals after destroying the one remaining labyrinth, 
the first one having been previously destroyed and the 
symptoms of the destruction disharmony having been 
recovered from. So when the labyrinth, from a serous 
or purulent inflammation, ceases to functionate, its im- 
pulses are cut ofl' from the intricate nervous mechanism 
which regulates equilibrium and orientation and the 
symptoms of destruction disharmony result. There is 
regularly impairment of hearing wliich tests show to be 
due to a lesion of the perceptive mechanism. It varies 
with the severity of the process, at times deafness becom- 
ing absolute. The caloric and rotation tests may or may 
not be positive. The nystagmus to the oj^posite side, 
besides the other symptoms of destruction disharmony, 
is caused l)y some interference with the movement of 
the endolymph within the labyrinth. As soon as this is 
sufficient to produce an imbalance nystagmus results. 
The endolymph may still be cai)able of movement, 
although it does not move with sufficient freedom to stimu- 
late the cristre ampullae as in a normal labyrinth. The 
currents produced by the caloric, rotation and fistula 
tests, being much more powerful than the physiological 
currents in the fluid, may still be ca])able of so stimulat- 
ing the cristie that the involved labyrinth becomes the 
predominating one in producing an imbalance and hence 
the tests be positive. 

Diagnosis. — The diagnosis is made upon the presence 
of the vertigo and nystagmus to the opposite side in 
conjunction with the result of the tests of hearing and 
the irritability of the static labyrinth. The following 



SEROUS LABYRINTHITIS 325 

table from Ruttin shows the tests in the various stages 
of labyrinthitis : 





1 


2 


3 


Hearing . 


. + 


— 


- 


Caloric 


. + 


+ 


— 


Rotation . 


. + 


+ 


+ 


Fistula 


. + 


4- 


+ 



+ 

The four tests are arranged according to their delicacy 
and in the order in which they are usually lost. As long 
as the reactions are represented by the first four columns 
the process may be considered a serous one. When all 
of the reactions are lost as in column 5 it may still be 
serous but there are no means yet known to determine 
that such is the case. If after a week or so the reactions 
begin to return, then it is fair to assume that the process 
has been a serous one all the time and that it is now 
resolving. However, during the absence of the reactions 
it so closely resembles a purulent labyrinthitis that there 
is no difference in the clinical picture of the two diseases. 

Prognosis. — The disease may pass into the purulent 
type of labyrinthitis or may result in cure with more or 
less impairment of hearing. In mild types this may 
return to practically as good as before, while in the severe 
types total deafness may result. The vertigo usually 
passes away in from three to ten days, although a mild 
degree may persist for some time. This is also true of 
the nystagmus, although at times it seems slow to disap- 
pear. The author has under observation a patient in 
whom the nystagmus to the opposite side is still present 
some four months after the attack of serous labyrinthitis. 

Treatment. — As long as the labyrinthitis is of the serous 
type, there are no bacteria in the labyrinthine cavity 
and there is no danger of meningitis; therefore opera- 
tion is not indicated. Moreover, it is not unreasonable 
to expect the patient to get well w^th some return of 
function. The only reason which would justify opera- 
tion is that the diagnosis between serous and purulent 
labyrinthitis could not be made, and one would then 



326 SUPPURATIVE DISEASES OF LABYRINTH 

be operating upon the assumption that the disease was 
no longer serous in nature. If the reactions have been 
gradually lost, one at a time during a few days, one 
would be justified in postponing operation, although this 
history may occasionally be given in purulent processes. 
So the patient is treated expectantly with rest in bed, 
light diet, and laxatives. 

PURULENT LABYRINTHITIS. 

Definition. — Sui)purative labyrinthitis is either mani- 
fest or latent. The term manifest is applied to those 
processes in which the symi)t()ms of destruction dis- 
harmony are present. As nature accustoms herself to 
the loss of the impulses normally derived from the 
destroyed labyrinth the symi)t()ms disappear, and the 
process becomes latent. Wlu^thcr it is ])()ssible for the 
destruction of the labyrinth to take i)lace so gradually 
in this disease that the symptoms of the disharmony may 
never be present is undecided. It must, however, be of 
rare occurrence, although patients occasionally present 
in the latent stage who give no history of the symptoms 
of the manifest stage. 

Causation. — The disease is an infective process involv- 
ing the whole labyrinth. Infection may occur through 
the oval and round windows, through a fistula in the 
promontory or any part of the labyrinthine capsule, or 
it may be secondary to a purulent meningitis, or be due 
to septic embolism of the internal auditory artery, 
although usually the process follows directly upon middle- 
ear disease. Penetrating wounds of the labyrinth as by 
the introduction of a foreign body or by the instruments 
of the surgeon, are usually followed by purulent inflam- 
mation. A myringotomy knife entering the oval window, 
a defect in the annular ligament of the stapes caused by 
traumatism inflicted upon this ossicle during operation, 
or the accidental extraction of the stapes in an infected 
field, are each sufficient to produce a suppurative laby- 



PURULEXT LABYRIXTHITIS 327 

rinthitis, or the disease may follow operations in which 
no known traumatism upon the labyrinth has been pro- 
duced. 

Pathology. — The membranous lab\Tinth becomes in- 
flamed and infiltrated with round cells. The delicate 
membranes in the cochlea, especially Reissner's, rupture 
and the endo- and perilymph spaces become filled with 
purulent material. An abscess may develop in the 
internal auditory meatus which may be walled oft' from 
the general meninges by adhesions. This abscess may 
cause destruction of the internal auditory artery which 
supplies a considerable part of the bony lab\Tinth, and 
this may lead to necrosis of the whole or part of the 
labyrinth. The infection may extend to the meninges 
thi^ough the internal auditory meatus, tlu'ough the aque- 
ductus cochleae, or more rarely through the aqueductus 
vestibuli. The infection in the latter may result in 
empyema of the ductus endolymphaticus or an inter- 
dm^al abscess which may in tiu^n lead to cerebellar abscess. 
There is regularly degeneration of nerve tissue within 
the labyrinth, although at times it seems quite resistant. 
As the process goes on, there may be in some instances 
formation of fibrous tissue or new bone so that the 
lab^Tinthine cavity becomes completely filled with this 
tissue. If this exists the process may be considered as 
healed. As restoration of function never takes place, 
the most that can be hoped for is healing with the bone 
or fibrous tissue, in which event it may be considered 
probable that the menace to life from complications is 
at an end. 

Pa?i Otitis. — [Many years ago Pohtzer described a form 
of purulent labyrinthitis occurring in acute otitis media 
under the name Pan Otitis. The middle ear and laby- 
rinth were apparently simultaneously involved. The 
disease occurred most frequently in children, upon one 
side only or upon both sides. There was a febrile attack 
of greater or less severity accompanied by vertigo and 
vomiting. ^Yhen the patient recovered, profound or 



328 SUPPURATIVE DISEASES OF LABYRINTH 

total deafness was present. Examination of the mem- 
brana tympani, after recovery, showed evidences of 
middle-ear suppuration, although in some instances these 
could with difficulty be made out. 

Symptoms. — In the manifest form there is deafness, 
vertigo, nausea and vomiting, nystagmus to the healthy 
side, and if the patient tries to walk, a staggering gait. 
The patient usually takes to bed and lies upon his well 
side. This decubitus is quite characteristic and also 
occurs in serous labyrinthitis. It is due to the patient's 
subjective sensation of rotation which is part of his 
vertigo. He finds this increased wlicn he looks in the 
direction of the rapid component of liis nystagmus and 
less when he looks in the direction of the slow component. 
So he lies upon his well side and is thereby enabk^d to 
look in the direction of the slow c()m])()nent of his 
nystagmus which is toward the diseased side, since the 
rapid component is toward the good side, as above 
stated. If he adopts any other i)()siti()n he usually 
keeps his eyes closed. There may be some fever but 
only of a degree or so. Fully as often the disease is 
afebrile. This is not unreasonable when one considers 
how small the labyrinthine space is and that the absorp- 
tion of the products of inflammation which produce fever 
is not so free from the inside of a bony cavity. If there 
is a rise of more than one degree in the temperature, the 
occurrence of some intracranial complication, probably 
meningitis, should be suspected. Severe pain ought also 
to suggest meningitis. If the labyrinth is tested during 
this manifest stage, it will be found to give no response 
to any of the four tests. After a varying time, from 
three to nine days, the vertigo disappears. It is usually 
mild after the first three days. The author had one 
patient in whom it lasted but twenty-four hours. The 
nystagmus, however, is usually slower in disappearing 
but it usually becomes of milder degree in from one to 
three weeks. When it becomes nearly absent the patient 
may be considered to be in the latent stage. The terms 



PURULENT LABYRINTHITIS 329 

manifest and latent are merely used for convenience. 
There is no exact dividing line between them. When 
the patient has no symptoms referable to his labyrinth 
except deafness or tinnitus he is usually considered to be 
in the latent stage. He still remains negative to the four 
tests and if he comes under observation during this stage, 
these tests, the evidences of a suppurative ear process and 
the history of the manifest stage usually are present. If 
he does not give a history of vertigo, one may be in doubt 
but these instances are not common. If upon rotation 
it is found that compensation has occurred, it is fair to 
assume that the process within the labyrinth is a healed 
one. 

Sequestration, — In the latent stage occur the results of 
those processes which produces death of a whole or part 
of the labyrinthine capsule. The sequestrum may be 
extruded and discharge with the aural pus. In this case 
it is usually some small part of the cochlea. Or it may be 
found lying in a bed of granulations at the operation. 
Outside of the tests usually present in the latent stage, 
facial paralysis is often present in sequestration. It is 
difficult for a sequestrum of any size to form which is 
composed of labyrinthine capsule, without at the same 
time affecting the Fallopian canal, so the occurrence of 
facial paralysis in a patient with diffuse suppurative 
labyrinthitis should always lead one to suspect seques- 
tration. 

Prognosis. — The prognosis of suppurative labyrinthitis 
is bad. While many patients may have the condition 
for years and in some it becomes a healed process, the 
danger of meningitis and cerebellar abscess is so great 
that it must be considered a very serious condition. 

Treatment. — Outside of the usual measures adopted in 
any inflammation in the temporal bone, the treatment 
of suppurative labyrinthitis is a subject fraught with 
difficulties. Some surgeons are so ''conservative" that 
they only operate when meningitis is ''imminent," being 
mainly guided to this conclusion by rise in temperature 



330 SUPPURATIVE DISEASES OF LABYRINTH 

or headache. If the operation is done then, the menin- 
gitis has already begun and it is too late in most instances, 
although a patient is occasionally saved. If death occurs 
under these circumstances, it cannot be attributed to the 
operation. Then, again, some patients get well; that is, 
apparently so, although with loss of function, without 
operation. The proportion that do this is by no means 
negligible. Nevertheless there can be no doubt but that 
a patient with a suppurating labyrinth is better off if it 
is drained. The mortality would certainly be less if every 
such labyrinth was opened by a skilful operator thoroughy 
equipped by dead-house work to perform the operation. 
Before the radical operation every patient should have 
his reactions taken and if a latent suppurative process is 
present, the labyrinth should be drained at the time of 
the radical operation or the latter not performed. An 
exception to this rule may be made when compensation 
has occurred — indicating a healed process. When there 
is latent diffuse labyrinthitis with facial paralysis, the 
radical operation should be done, search made for a 
sequestrum and, if found, removed. 

PERILABYRINTHITIS. 

Definition. — The term perilabyrinthitis is applied to a 
certain variety of clinical manifestation that cannot 
with consistency be called by any of the other names 
used to designate the processes complicating middle-ear 
suppuration. It is probable that as the knowledge of 
labyrinthine conditions become more complete, the term 
will become obsolete, as there are many objections to its 
use. 

Pathology. — The lesion is supposed to be an inflam- 
mation of the bone contiguous to the labyrinthine cap- 
sule involving to a certain extent the capsule itself. As 
the processes coming under this head are not fatal unless 
they pass into some of the other forms of labyrinthitis, 
reports of autopsies in patients afflicted with this con- 



PERILABYRINTHITIS 331 

dition are not forthcoming and the exact nature of the 
basis of the disease is more or less a matter of speculation. 
It occurs after the radical operation, less often after simple 
mastoidectomy and as a complication of a suppurative 
process in the middle ear and mastoid. 

Symptoms. — The patient usually comes on account of 
the vertigo which he experiences. This is not the profound 
dizziness of manifest suppurative or serous lab^Tinthitis 
but is milder. Some patients complain of more or less 
continuous vertigo which does not compel them to go to 
bed as a rule, but may render them unfit to pursue their 
vocations. It is not accompanied with vomiting except 
in rare instances. This dizziness is aggravated or brought 
on by sudden movements of the head. In other patients 
the vertiginous symptoms come in attacks, while between 
the attacks they are more or less free. If these patients 
are made to hop forward or backward with the eyes 
closed, they usually, but not constantly, show a tendency 
to fall, but the author has been unable to note that there 
is any constant relation between the direction of the 
tendency to fall and the side supposed to be involved. 
There is regularly nystagmus, usually of mild degree, seen 
in the extreme lateral position of the eyes and either to 
the involved side or to both sides. 

The hearing is not affected or but moderately so. The 
caloric and rotation tests show a normal or increased 
irritability of the labyrinth and the fistula symptom is 
negative. 

Diagnosis. — The diagnosis is to be made by excluding 
the other forms of labyrinthine disease. The only one 
which it resembles is circumscribed labyrinthitis. From 
this it is separated by the increased irritability to the 
caloric and rotation tests which is usually present and by 
absence of the fistula symptom. 

Prognosis. — The prognosis is usually good, although 
a patient having this form of disease may occasionally 
develop one of the other and more dangerous types of 
labyrinthitis. 



382 SUPPURATIVE DISEASES OF LABYRINTH 

Treatment. — When the condition follows the radical or 
simple mastoid operation, the treatment is largely expec- 
tant. Full doses of the bromides are at times of benefit. 
Pilocarpine may also be given and at times seems to be 
of some value. The patient is supplied with a 2 per cent, 
solution of the hydrochlorate and directed to take two 
drops at night for three days, then if the physiological 
action of the drug has not manifested itself by sweating 
or flow of saliva, the dose is increased by one drop every 
three days until these symptoms do occur. The drug 
should be watched carefully, as at times it makes the 
patient feel weak instead of producing sweating or flow 
of saliva, indicating that the dose is too large. When 
perilabyrinthitis occurs on account of a chronic su])])ura- 
tion or an acute mastoiditis, an o])eration is indicated to 
remove, if i)()ssiblc, the involved area adjacent to the 
labyrinthine capsule. 

LABYRINTH OPERATIONS. 

Choice of Operations. — Lal)yrinth ojH'rations may be 
divided into two classes: (1) Those wliich have as their 
object ()])ening and draining the hd)yrinth; (2) those 
which while acc()m])lishing this are continued further 
and the internal auditory meatus opened and the dura 
in the middle and ])osteri()r fossa^ ex])ose(l. The first 
are to be performed when the infective process is still 
confined to the labyrinth, and the second when invasion 
of the meninges has occurred or seems imminent. As 
has been seen in the preceding pages, the indications for 
labyrinth operations are still somewhat indefinite; but 
granting that an operation is necessary in a given patient, 
the decision as to the procedure to be adopted largely 
rests on the intracranial condition. If an abscess has 
formed in the internal auditory meatus, or if there is a 
meningitis on the posterior surface of the petrous pyramid, 
or if there is a serous meningitis due to a labyrinthine 
suppuration, labyrinthine drainage would be futile, as it 



LABYRINTH OPERATIONS 



333 



would also in a general meningitis from infection through 
the labyrinth. On the other hand, when the process is 
limited to the spaces within the labyrinth or one feels 
reasonably sure that this is the case, one w^ould hesitate 
before subjecting a patient with such a process to the 
more severe sm-gical procedure, but would be content 
with lab^Tinthine drainage. 



fl 




Fig. 110. — Author's set of labyrinth gouges and chisels. 



Preliminary Operation. — ^These operations can only be 
performed after the radical operation, so if it becomes 
necessary to do one in a patient who has not previously 
had this operation performed, it must be done as a pre- 
liminary procedure. A very thorough operation is 
necessary, the facial spur must be taken down to its 
extreme limit, all cells and soft tissue removed so that the 
white ivory-like bone of the lab}Tinthine capsule shows 
to as great an extent as possible. The promontory of the 
cochlea and the horizontal semicircular canal show plainly 



334 SUPPURATIVE DISEASES OF LABYRINTH 

in the radical operation, but it may be possible after the 
soft bone is removed to see the posterior and part of the 
superior canals also. The operator must be thoroughly 
acquainted with the anatomy of the parts, in fact, possess 
such a knowledge as can only be derived from a frequent 
performance of the operation on the cadaver. The 
operation then becomes one of no great difficulty and 
adds very little to the mortality even if it is not the 
means of saving the life of the patient. It is because the 
operation is deferred until the process demanding it is 
practically h()])eless that the mortality is so high. Anyone 
competent to do a radical ()i)erati()n, if he will take the 
pains and time necessiiry, can become al)lc to perform the 
labyrinth ()j)erati()n with skill and safety. 

Instruments. — The instruments necessary are those with 
which tlic radical operation is done, a set of gouges and 
chisels (Fig. 110) and a very fine i)r()be. 



LABYRINTHINE DRAINAGE. 

This procedure is termed labyrinthine drainage, as the 
prime objects of the operation are to open the vestibule 
and cochlea, thus affording thorough drainage to a puru- 
lent process within the labyrinth. This nuich can be 
accomplished in any type of bone by the procedure about 
to be described. In many instances the whole canal 
system can be removed if thought advisable, but if there 
is a low middle fossa with a far forward sinus the technical 
difficulties encountered in trying to accomplish this may 
be very great. 

Guide to the Vestibule. — The vestibule is to be opened 
first, the guide to this cavity is the horizontal semicircular 
canal, the anterior or ampullated extremity of which 
opens into the vestibule at its anterior and upper part, 
w^hile the posterior end opens into this cavity at its pos- 
terior and upper part. It is evident, therefore, that the 
bone between these two ends is the roof of the vestibule, 



LABYRINTHINE DRAINAGE 335 

and it is this roof which it is proposed to take away, 
thereby opening and draining this cavity. 

Opening the Horizontal Semicircular Canal. — The first 
step is to open the horizontal semicircular canal and trace 
its lumen from end to end. The anterior half or two-thirds 
of this canal is immediately above the facial nerve. In 
this situation the upper wall of the Fallopian canal and 




Fig. 111. — Labyrinthine drainage. Horizontal semicircular canal 

opened. 



the lower wall of the semicircular canal are one and the 
same process of bone. This lies over the oval window 
and the osseous semicircular canal is the real support of 
the facial canal in this location, so in opening the lumen 
of the anterior part of the horizontal canal and in the 
further progress of the operation, all of the inferior 
and as much as possible of the external wall should be 



336 SUPPURATIVE DISEASES OF LABYRINTH 

preserved. So with a bent gouge a pit is started above 
and slightly internal to the concavity of the horizontal 
semicircular canal. Working outward, shaving after shav- 
ing is taken until the canal is opened. This opening is 
then extended until the two ends of the canal are reached 
(Fig. 111). A fine probe can now be passed into the 
vestibule through either end of the canal. 

Opening the Vestibule. — This locates the vestibule and 
the bone between the two ends of the horizontal canal 
must be removed. This can be done with the two bent 
gouges, with the one working from behind forward and 
with the other from before backward, deej)ening the pit 
already started, and taking care not to encroach on the 
floor of the semicircular canal in its anterior half or two- 
thirds. If there is room l)etween the descending part of 
the facial nerve and the posterior cranial fossa, a gutter 
may be formed in the angle between the i)osterior semi- 
circular canal and the posterior end of the horizontal 
canal. This is termed the hard angle, and the gutter 
formed in this angle may remove the posterior end of 
the horizontal canal and part of the posterior canal also. 
This will afford more room to remove the roof of the 
vestibule. The operator must keep the two ends of the 
horizontal canal always in view and not allow them to 
become filled with debris and thus obscured. At times in 
completing the opening in the vestibule a very narrow 
chisel is useful. 

After the vestibule is opened, if the operator desires 
to remove the posterior and superior semicircular canals, 
he proceeds to do so. In removing the superior canal in 
its entirety it is necessary to expose the dura and remove 
the inner table to a point internal to the eminentia 
arcuata. The anterior end is opened with the bent gouges 
which are also very useful for opening and tracing the 
posterior canal. 

Opening the Cochlea. — The next step is removing the 
internal tympanic wall over the cochlear whorls. The 
first turn is opened by removing the promontorj' and 



LABYRINTHIXE DRAINAGE 337 

the process of bone between the oval and round windows. 
This is best done with a small gouge. The cutting edge 
is placed upon the promontory immediately below the 
oval window, and a shaving taken in a downward direc- 
tion extending to near the floor of the tympanum. The 
instrument is pointing dii^ectly toward the jugular bulb 
in this situation and must be under perfect control. The 
sha\'ings taken must be thin, as if thick ones are taken the 
gouge may jam into the cavity of the cochlea and fracture 
the modiolus. This accident, as sho^vm by Richards^ not 
only allows the escape of cerebrospinal fluid but also 
opens an avenue through which infection may extend to 
the meninges. The fluid drains through the openings 
caused by tearing the meningeal sheaths which accom- 
pany the nerve fibers to a certain distance after they 
enter the modiolus. After the promontory is removed 
there is usually left a triangular piece of bone between 
the oval and round windows, the third side being formed 
by the margin of the cut in the promontory which has 
been made with the gouge. A curette may be carefully 
inserted, just taking this edge and by withdrawing it the 
bone is drawn out with safety. This completes the open- 
ing of the first cochlear turn and, unless it is determined to 
open the second turn, the operation also. 

Facial Nerve. — A bent probe can now be passed from 
the cavity made while opening the vestibule through the 
cochlear opening into the lower part of the tympanic 
cavity (Fig. 112). In this position it lies beneath a bridge 
which has been formed by the operation. This consists 
of the Fallopian canal reinforced by the lower, and as 
much as has been left of the external wall of the hori- 
zontal semicircular canal. This bridge should always be 
left, as to remove it produces permanent facial paralysis 
and does not add materially to the drainage. Even though 
it should be found partly necrotic as it may be in some 
instances of labyrinthine sequestration, an attempt 
should be made to leave as much of it as possible, as no 
substitute can be found for even a small part of the 
22 



338 SUPPURATIVE DISEASES OF LABYRINTH 

Fallopian canal. This is the best structure to support 
the nerve and thus minimize facial paralysis. 

Second Cochlear Whorl. — If it is determined to open the 
second turn of the cochlea, this can be done with the 
gouge. The bone covering it appears pearly white upon 
the internal tympanic wall anterior to the opening made 




Fig. 112. — LMbyrinthinc draiiuiRc. Vestibule opened posteriorly and 
above; promontory of the cochlea renio\etl. Probe i)asses beneath the 
bridge containing the facial nerve. 



by removal of the promontory. Thin shavings are taken 
from this surface until it is opened. The carotid artery 
lies in front, the jugular bulb below and the facial nerve 
above the area to be removed; so considerable care is 
necessary to avoid these structures. While it is a ques- 
tion how much additional drainage is afforded by opening 
this turn, the author has always felt when doing it on the 



NEUMANN'S OPERATION 339 

living, that it was more an exhibition of operative possi- 
biUties than a proceeding of decided vahie. 

After-treatment. — The after-treatment of this labyrinth 
operation is very mnch the same as in the radical opera- 
tion. Xo primary graft is applied. If the patient does 
well, a secondary graft may be inserted in two or tliree 
weeks, when the posterior wound may also be closed, as 
this is usually left open temporarily after this procedure. 

Neumann's Operation. — Of the second type of opera- 
tions on the labyrinth, that introduced by Neumann is 
the one usually done. 

Locating the Vestibule. — The first step is exposing the 
lateral sinus. This is done in the same manner as m 
sinus thrombosis (which see). After the internal 
border of the sinus is exposed the bone is removed in 
Trautman's triangle either with the rongeur, curette or, 
as Neumann advises, with a chisel. The dura is to be 
separated from the bone and with the chisel pieces are 
taken from the posterior surface of the petrous pyramid. 
These shavings are very apt to jam between the dura and 
the bone and must be removed as they are formed. The 
author has found the curette a very useful instrument 
in this step of the procedure. It can be introduced 
between the dura and inner table and by using the pos- 
terior edge of the bone wound as a fulcrum the pieces 
taken are removed with expedition and safety. This is 
continued until the posterior semicuTular canal is reached. 
This is opened and its prominence removed. A fine 
probe will now pass through either opening into the 
vestibule. The lower one enters through the ampullated 
extremity of the canal into the lower part of the vestibule 
while the upper enters tlii^ough the crus commune to the 
upper and back part of this cavity. These two openings 
are therefore the guides to the vestibule. 

Opening the Vestibule. — As the removal of the bone 
shavings from the posterior sm^face of the petrous pyramid 
is continued a third opening develops between the other 
two. This is the posterior end of the horizontal canal 



340 SUPPURATIVE DISEASES OF LABYRINTH 

and furnishes an additional guide to the vestibule (Fig. 
113). This cavity is soon opened. When it is freely 
exposed one may be working very near the descending 
limb of the facial nerve, the location of which may be 
determined by estimating how much of the posterior 
end of the horizontal canal has been removed, as the nerve 
turns downward about in the middle of this canal or at 
the junction of its middle and posterior third. 




Fig. 113. — Neumann's labyrinth operation, showing the two openings 
of the posterior semicircular canal and more anteriorly (to the left) 
the posterior end of the horizontal semicircular canal. 

Opening the Internal Auditory Meatus. — The next step is 
the removal of the triangular process of bone which Hes 
between the vestibule and the internal auditory meatus. 
This meatus ends at the vestibule, as the vestibular 
nerves occupy its posterior part and some of them pass 
directly into the vestibule, which thus becomes the 
guide to the internal end of the meatus. With the curette, 
small gouges and chisels the triangular piece of bone is 
removed, taking care that the diu*a is separated from the 
bone. Neumann advises that the dura in the middle 



NEUMANN'S OPERATION 



341 



fossa be exposed but the author prefers to leave the mner 
table in this location until the end of the operation for 
two reasons: (1) There is more danger of wounding the 
superior petrosal sinus if the angle of bone between the 
posterior and middle fossae is taken out. This has occiu-red 
and the bleeding is a serious matter, as the field becomes 
completely obscured; (2) this process supports the bone 
upon which one is working and prevents fracture in some 
untoward locality. That this danger is real is shown by 




Fig. 114. — Neumann's labyrinth operation. The internal auditory 
meatus opened but not incised. 



the sensation of instability communicated to one's hand 
at each stroke of the mallet. iVs removal of this triangular 
piece proceeds a bent probe passed between the dura and 
posterior surface of the petrous pyramid will soon slightly 
enter the internal auditory meatus. Thus both ends 
of the meatus being established, it only remains to remove 
the bone between them, when the dura lining the internal 
auditory canal is exposed (Fig. 114). This is opened by 
a longitudinal incision. If an abscess is found, no further 
dural incision is to be made unless meningitis is known to 



342 SUPPURATIVE DISEASES OF LABYRINTH 

be present. If an abscess is not discovered, the incision 
should be continued into the cerebellar dura. The dura 
in the middle fossa may now be incised, the inner table 
being removed if it has not already been done. 

Cochlear Drainage. — Before these dural incisions are 
made it is usually a good plan to open the cochlea. This 
is done in exactly the same manner as described under 
Labyrinthine Drainage. 

After-treatment. — In some patients the flow of cerebro- 
spinal fluid is quite free for from twenty-four to forty- 
eight hours, when it generally ceases from the formation 
of adhesions. In others it is scanty or al)sent. The 
dressings are cluinged daily or every second (hiy and the 
wound heals l)y granulation and dcrmatization as any 
radical cavity. 



CHAPTER XI. 

CO^ylPLICATIOXS OF PURULENT OTITIS 
MEDIA. 

MENINGITIS. 

^Meningitis as seen by the otologist may be discussed 
under four heads: (1) External Pachymeningitis. (2) 
Circumscribed jNIeningitis. (3) Purulent Leptomenin- 
gitis. (4) Serous Meningitis. 

External Pachymeningitis. — External pachymenin- 
gitis as usually seen is the ordinary extradural abscess. 
As the disease in the mastoid progresses the internal 
table breaks down and the pus accumulates between the 
dura and the bone. In some instances one feels inclined 
to believe that this has taken place, being led to this 
conclusion by the sudden cessation of severe pain or 
diminution of the discharge. If pain in a given process 
is caused by pressure of pus within the mastoid, rupture 
of the inner table removes the tension and relieves the 
pain and may also cause a diminution of the amount of 
the pus which appears in the meatus. The dura reacts 
to this purulent irritation and granulations of varying 
size form upon its external. surface. It is not an infre- 
quent occurrence to see granulations as thick as one's 
finger during operation upon patients, in w^hom the 
process has been going on for some time and has been 
neglected. The treatment is considered under the mastoid 
operation. 

In another type the internal table is softened over a 
very small area or the infection has extended through 
without breaking down the bone. There is a purulent 
inflammation of the external dural layers and the pus 



344 COMPLICATIONS OF PURULENT OTITIS MEDIA 

accumulates between this membrane and the bone, 
exceptionally in sufficient quantity to cause increased 
intracranial pressure and, if in proper position, the 
localizing symptoms of brain abscess. 

Diagnosis. — The diagnosis of these processes may be 
difficult. One may be led by the sym])toms to suspect 
some pathological intracranial condition and ui)on expos- 
ing the dura discover the abscess. One sym])tom which 
should never be neglected is the sudden discharge of a 
quantity of pus. A mastoid operation may have been 
performed and the woimd apparently healing normally 
when, upon removing the ])acking, pus will be present 
in varying quantity, bacteriological examination of this 
pus will furnish some information. The germs causing 
a mastoiditis usually soon disa])])car after o])eration, as 
smears taken from the wounds soon show that the ])re- 
vailing germ cannot be found; so if this germ is i)resent 
in this purulent secretion which ai)])cars in a wound 
l)reviously normal, its source should be investigated. 
It may be absent for a dressing or two, then reap])ear. 
One may at times be able to detect the location from which 
the discharge comes or the i)robe may reveal the opening 
or necrotic bone in its vicinity. Politzer was able to 
demonstrate the presence of such an abscess in the middle 
fossa by means of the otosco])e. ri)()n rarefying the air 
in the meatus pus was drawn through a small i)erf()ration 
in the tegmen tympani. One should think of this form 
of meningitis when trying to ascertain the cause of heafl- 
ache, especially if localized about the ear. 

Treatment. — The treatment is to open and drain the 
abscess, removing sufficient bone to accom])lish this, and 
is to be carried out along the lines described under the 
simple mastoid operation. 

Circumscribed Meningitis. — Occasionally the internal 
surface of the dura and the pia arachnoid become inflamed 
and instead of spreading the process becomes circimi- 
scribed. If the condition progresses, the external surface 
of the brain breaks down and an abscess is formed. Cases 



MENINGITIS 345 

of circumscribed meningitis with ulceration of the brain 
are usually reported as ''brain abscess." The surgeon 
incises the dura and pus is discharged which contains 
broken-down brain tissue, the abscess really lying within 
the meninges (subdural) in contradistinction to true brain 
abscess which is located within the brain substance. 

Causation. — The process is usually caused by contiguous 
extradural abscess, either infection of the internal surface 
of the dm*a and pia arachnoid, in which event the localized 
inflammation is purulent, or swelling and edema of the 
dura results in the effusion of serum within the subdural 
space, which becomes circumscribed by adhesions. A 
sinus thrombosis in which the clot breaks down may be 
the cause, the meninges adjacent to the internal sinus wall 
becoming involved. 

Symptoms. — The symptoms in the early stages are very 
much like those of general meningitis but not as severe. 
In the later stages they very closely resemble those of 
brain abscess. In the serous type there may be no symp- 
toms, the surgeop on account of the tense character and 
perhaps also some discoloration of the dura, being led 
to suspect the presence of an accumulation of fluid, 
incises the membrane, evacuating the fluid, or there may 
be pain and increase of temperature, as in the early stage 
of the purulent process. 

Diagnosis. — In diagnosing these processes one has the 
findings of the mastoid or radical operation as a start. 
If some condition has been found that would conduce to 
meningeal inflammation and the symptoms of meningitis 
develop and upon examination of the spinal fluid it is 
found to be not far from normal, one comes to the con- 
clusion that the process is localized. It may be impos- 
sible to separate the process from brain abscess, in fact 
the difference may not be discovered until operation or 
not even then, the two conditions resembling each other 
so closely in some instances. 

Prognosis. — ^These circumscribed processes, if recognized 
and treated surgically, offer a good prospect of cure, 



346 COMPLICATIONS OF PURULENT OTITIS MEDIA 

although at times they may eventuate in general menin- 
gitis. ^ ^ 

Treatment. — The treatment is to afford free drainage 
by incising the dura. In making this opening care should 
be taken not to extend it beyond the limits of the circum- 
scribing adhesions, at the same time it must be suffi- 
ciently free to afford drainage. A cigarette drain or 
folded rubber tissue may be inserted to keep the dural 
wound open. No examination of these cavities either 
with the finger or any instrument is to be allowed, as 
nature's barrier adhesions may be broken down and the 
process thus become general. 

Purulent Leptomeningitis. — Purulent meningitis of 
otitic origin is the bete uoir of the otologist. The possi- 
bility of its occurrence makes every case of suppurative 
middle-ear disease a serious matter. 

Causation. — It may be caused by acute or chronic 
suppuration in the middle ear or mastoid or be due to 
rupture of a brain abscess either into the ventricles or 
upon the surface of the brain. The infection may reach 
the meninges through a wound of the dura, produced 
during operation, or from an infected sinus or extension 
of an extradural abscess. Solution of continuity of the 
dura is not necessary, as the infection may extend by a 
clot in the small veins or through the lymphatics. Infec- 
tion may be transmitted in this manner through the 
vessels and lym])hatics which exist between the tympanic 
vault and the middle fossa or there may be a dehiscence 
in this location, the mucous membrane in the middle ear, 
on account of this defect, comhig into very intimate 
relation with the dura. Instances are on record in which 
the meningitis was caused by evulsion of a polyp which 
had its attachment to the soft structures in such a dehis- 
cence. The infective process may travel along the nerves. 
In this manner involvement within the Fallopian canal 
may cause meningitis, the infection reaching the meninges 
either through the hiatus Fallopii or the internal auditory 
meatus. The petrosal branches of the tympanic plexus 



MENINGITIS 347 

also perforate the tegmen tympani and may forra the 
avenue of infection. Wittmaak^ beHeves that bacteria 
may find their way from the hypotympanum to the 
meninges through the small vessels and along the nerve 
sheath of the tympanic branch of the glossopharyngeal, 
thus gaining entrance to the process of the meninges 
which surrounds the ninth, tenth and eleventh cranial 
nerves in the jugular foramen. Of special importance as 
causing meningitis is suppurative disease of the labyrinth. 
The usual route of extension is through the internal 
auditory meatus^ next in frequency the aqueductus 
cochleae, and less often the aqueductus vestibuli. At 
the internal auditory meatus the circulatory arrangement 
seems very favorable for the transmission of infection 
from the lab\Tinth to the meninges. Practically the 
entire blood supply of the labyrinth passes through the 
internal auditory meatus; moreover, at the fundus of this 
canal the thin shell of bone is perforated to transmit the 
vessels and nerves which in some locations are covered 
with meningeal processes even after their passage through 
the foramina, x^ttention has already been called to the 
effort on the part of nature to limit the infection in this 
canal and the consequent production of an abscess. If 
not relieved promptly these abscesses rupture, leading to 
meningitis. 

Pathology. — In purulent leptomeningitis there is injec- 
tion of the pial vessels, formation of a purulent exudate, 
softening of the cortex and more or less edema of the 
brain substance. There is increase of the cerebrospinal 
fluid which is first clear, afterward cloudy or purulent. 
The ventricles may be distended and intracranial pressure 
increased. The fluid also collects in increased amount 
in the various cisterna of the pia arachnoid. The process 
also extends to the spinal meninges. There is absorption 
of the products of inflammation and symptoms caused 
by loss of function of the brain cortex, especially at the 
base. 

1 Zeitschrift f. Ohrenhoilk., vol. xlvii. 



348 COMPLICATIONS OF PURULENT OTITIS MEDIA 

Course and Symptoms. — A purulent meningitis may run 
an acute course, death taking place in twenty-four to 
forty-eight hours. This very acute or fulminating type 
is apt to follow rupture of a brain abscess into the ven- 
tricles. More often the course is slower and death does 
not occur for a week or so, while in some patients the 
disease seems to be more chronic or even latent for short 
periods of time. Sometimes one of these latent types is 
lighted up into an acute form by the performance of the 
radical operation. Alexander advises a lumbar puncture 
at the time of operation, if any suspicious symptoms are 
present, to ascertain whether or not the meningitis is 
due to operative interference, and T. Passmore Berens 
goes a step further and proposes to do a lumbar puncture 
even in the absence of symptoms, being influenced in 
this decision by the observation of several patients with 
the latent form of meningitis. The most common symp- 
tom is headache, usually coming on early and remaining 
more or less continuous. It may be referred to the fron- 
tal or occipital regions or to any part of the head. Some- 
times it is more severe in the neck, radiating to the head. 
Rarely it is absent or not complained of, especially in 
latent types. Vomiting is also common either as a result 
of a manifest purulent labyrinthitis or as a symptom of 
the meningitis itself. There is regularly a rise of tem- 
perature. This may not be high but usually varies 
between 101° and 105° F. In the beginning the pulse is 
rapid wdth usually an increased arterial tension. After 
the development of increased intracranial pressure, it 
usually becomes slower but not slower than normal. 
There is increase of the reflexes and the patient is easily 
startled. 

The Kernig sign is usually positive, although this may 
occur in other conditions also. In a normal person the 
thigh may be flexed upon the abdomen to a right angle 
or even beyond without bending the knee. If the Kernig 
sign is positive it w^ill be impossible to bring it to a right 
angle w^th the trunk without bending the knee. The 



MENINGITIS 349 

Babinski sign may also be positive. If the sole of the 
foot of the normal person is lightly stroked, there will 
result flexion of the toes, especially of the great toe. If 
the Babinski is positive, stroking the sole will produce 
extension dorsall3^ 

There may be inequality of the pupils or they may 
not react normally. There may be various paralyses of 
the eye muscles. Abduceus paralysis is present in about 
3 per cent, of the cases. The fundus is very apt to show 
changes. In one hundred cases analyzed by the author, 
some change was noted in about one-third, in one-third 
it was absent, while in the remaining third the condition 
of the eye-grounds w^ere not mentioned. Yansen states 
that some change is present in about 50 per cent, of the 
patients. 

If the disease foUow^s a suppurative labyrinthitis, there 
may or may not be nystagmus, but there is loss of the 
reactions as characteristic of that disease. Stiffness of 
the neck is a very common symptom, in some instances 
the rigidity extends the entire length of the back, resulting 
in opisthotonos. As the disease progresses the patient 
passes into a semiconscious state and finally cannot be 
aroused at all. He cries out at times with a sharp moan 
that becomes truly distressing to hear. 

Diagnosis. — In making a diagnosis great reliance is 
placed upon the result of lumbar puncture. The fluid 
may or may not be under abnormal pressure, but the 
evidence afforded by its examination is of great value. 
A smear may be made and bacteria found but in the early 
stages a culture is necessary to determine their presence. 
Bacteria in the spinal fluid establishes the diagnosis of 
purulent meningitis. If the variety of germ is the same 
as found in the mastoid pus, it is a fair inference that the 
infection is from this location; if not, further search must 
be made to determine its source, which in some instances 
will be disease of the accessory sinuses of the nose. If 
bacteria cannot be demonstrated by culture, it does not 
necessarily follow that the patient does not have this 



350 COMPLICATIONS OF PURULENT OTITIS MEDIA 

disease. The author treated a patient who had purulent 
meningitis in whom repeated cultures failed to demon- 
strate the presence of any pathogenic microorganism in 
the spinal fluid, which was in other respects characteristic. 
The patient became steadily worse and died in about 
twelve days from the onset of symptoms. It was sus- 
pected that an anaerobic bacteria might have been 
present or that the meningitis was tubercular in nature. 
An attempt was made to ascertain the presence of tuber- 
cular bacilli b}^ inoculating a guinea-pig but without 
result. In another patient, who ran a fatal course in about 
four weeks, it was only upon the eighth lumbar puncture 
with cultivation of the fluid that a pneumococcus was 
demonstrated, the character of the fluid as well as the 
clinical manifestations, in the meantime, leaving no doubt 
as to the nature of the process. Before the culture is 
positive or to make a diagnosis and a(I()i)t treatment 
without waiting the necessary (twenty-four hours usually) 
time for a re})()rt of its result, certain characteristics of 
the fluid may be of value. 

The cerebrospinal fluid normally contains a suiall 
amount of sugar and readily reduces c()i)i)er by the Fehling 
test. It has been found that the growth of bacteria within 
the meninges may exhaust this sugar content. Thus 
absence of sugar becomes a sign of some value. It is 
difficult to estimate its true importance, but a disposition 
to consider it of small worth seems to be growing. Taken 
in conjunction with the leukocyte count, which is of far 
more importance, failure to reduce copper on the part 
of the fluid should have some weight in pointing to puru- 
lent meningitis. 

Normal cerebrospinal fluid does not contain more than 
ten leukocytes to the cubic millimeter. It is claimed by 
some to contain even less. Moreover, these cells are of 
the mononuclear variety. An increase in the number of 
cells and the occurrence of a substantial polynuclear per- 
centage is strong evidence of meningitis, although this 
may occur in cerebral syphilis, perhaps other conditions 



MENINGITIS 351 

also. In acute purulent meningitis that has once shown 
sufficient symptoms to make itself suspected there is 
likely to be very little chance of error, although many 
problems relating to the cerebrospinal fluid in disease 
of the central nervous system remain to be solved. A 
fluid in a suspected meningitis will usually contain suffi- 
cient leukocytes of the polynuclear variety to either con- 
firm one's suspicion or show that it is without foundation. 
It is impossible to state a number below which the patient 
does not have and above which he does have a purulent 
meningitis. The author has known the first lumbar 
puncture, in a fatal case of pmailent meningitis, to give 
fluid with a leukocyte count below 100 per millimeter, 
but this is by no means the lower limit. On the other 
hand, a puncture made late in the disease may draw fluid 
with a leukocyte count in the thousands. Xor can one 
make a diagnosis between purulent and serous meningitis 
on the leukocyte count alone, although a certain amount 
of evidence is afforded. The count should be low in 
serous meningitis but high in purulent meningitis. The 
author believed that the count should be under 60 in the 
serous process, but a recent experience has taught him that 
this is placing it too low. 

A patient with purulent labyrinthitis on the day 
following the onset of the disease had a temperature of 
101.6° F. but no headache. A lumbar puncture showed 
the fluid under pressm^e. Fehlings +, globulins +, leuko- 
c}i:es 145, polynuclears 70 per cent. The lab^Tinth was 
removed and the internal auditory meatus opened within 
foiu- hom's of the report above gi^Tn. After twenty-four 
hours the cultm-e was negative. The fluid drained from 
the wound for four days, the patient having nocturnal 
headache, some stiffness of the neck and a positive Iver- 
nig, the temperature varying between 99.8° and 102.6° F. 
The spinal fluid would not flow on lumbar punctm^e. 
This was attributed to the fact that the flow was so 
free from the wound. When this stopped and lumbar 
puncture was made seven days after the operation, the 



352 COMPLICATIONS OF PURULENT OTITIS MEDIA 

leukocyte count was 26, with a trace of the globuHns 
probably from some admixture of blood with the fluid. 
Culture and Wassermann both negative. This was 
probably a serous meningitis. 

The lumbar puncture and successive leukocyte counts 
also give one a fair indication as to the progress of the 
disease, providing no intraspinal injections have been 
made. 

Normal spinal fluid is free from the serum globulins. 
So if these are shown to be present by the butyric acid 
test, it becomes evidence of value of some meningeal 
process. It is always positive in purulent meningitis 
but, as has been shown, it may be i)()sitive in the serous 
form also. 

When a patient with a su])purative process of the ear 
complains of severe headache with elevation of tempera- 
ture, one ought always to suspect the presence of menin- 
gitis if careful examination fails to find other cause for 
these symptoms, especially if tlie mastoid or radical opera- 
tion has been done, thereby eliminating processes which 
are frequently the cause of temperature and pain. A 
lumbar puncture should be done upon the first suspicion 
of meningitis as an early diagnosis is in every way desir- 
able. For the latent types a lumbar puncture is the only 
method of diagnosis before the disease becomes active. 

Prognosis. — The prognosis of purulent meningitis is 
very grave. Some patients do get well and it is hoped 
that some treatment may be found that will give a better 
outlook. At present the surgeon, while doing all in his 
power for these patients, hardly dares to cherish the hope 
that his efforts will be successful. 

Treatment. — The best treatment is preventive. By an 
early removal of the source of infection in the mastoid, 
sinus or labyrinth, and by a careful operative technic 
which will reduce injury of the dura to the minimum, 
undoubtedly many patients may be prevented from 
developing meningitis. When it is once developed one 
must decide what he proposes to do in the hope of a cure, 



MENINGITIS 353 

and having formulated his plan of treatment, adhere to 
it. If the disease is due to suppurative labyrinthitis, the 
Neumann operation seems to offer the best prospect of 
ciu'e, however little it may be. If the meningitis is due 
to other otitic causes, a subtemporal decompression 
offers as much hope as any surgical procedure. This 
may be done as in the operation for temporosphenoidal 
abscess (Fig. 115), only the bone exposure is more exten- 
sive over the squama. A crucial incision is made in the 
dura to relieve the intracranial pressure. Sutures are 
passed around the branches of the middle meningeal 
arteries on either side of the dural mcision. This opera- 
tion may be made part of the lab\Tinth operation and the 
dura incised later when intracranial pressure becomes 
increased. After the operation autogenous vaccines, 
proper serum therapy, or the His leukocyte extract may 
aid to a cure. Cases have been reported in which the 
patient was cured by repeated lumbar punctures, others 
by the intraspinal injection of urotropin and the internal 
administration of this remedy, and still others in which 
nothing was done. 

Serous Meningitis. — Meningeal symptoms are some- 
times present without bacterial invasion of the meninges, 
as, when this occurs there is generally an increase of 
cerebrospinal fluid, the disease is termed Serous ]Menin- 
gitis. ^Nleningismus or meningeal irritation may wath 
propriety be considered as a variety of serous meningitis, 
although in this condition there may be no noticeable 
increase in the amount of the cerebrospinal fluid. 

Causes. — The causes are, suppurative processes in the 
temporal bone adjacent to the dura, suppurative labyrin- 
thitis and brain abscess. An extradural abscess, the 
inflammation being in such close proximity to the sub- 
dural space, seems favorably located to produce an increase 
in the cerebrospinal fluid. A temporosphenoidal abscess, 
lying as it does between the surface ^of the brain and the 
ventricles is able to produce an increase in the cerebro- 
spinal fluid in both regions. The abscess may or may not 
23 



354 COMPLICATIONS OF PURULENT OTITIS MEDIA 

be encapsulated, but the presence of the inflammation 
leads to edema of the brain substance and an exuda- 
tion of serum into the ventricles or on to the surface of 
the brain. A cerebellar abscess may act very much in 
the same manner but may also lead to pressure upon the 
aqueduct of Sylvius or the foramina which connect the 
fourth ventricle with the subdural space and lead to the 
retention of the cerebrospinal fluid within the ventricles. 
Thus, dilatation of the lateral ventricle not otherwise 
accounted for should lead one to suspect cerebellar abscess. 

The author operated upon a i)atient in whom this con- 
dition called his attention to the location of the abscess 
in the cerebellum. It was evident that some intracranial 
disease was present. Upon exploring the temporosphen- 
oidal lobe, the descending horn of the lateral ventricle 
was opened at a depth much less than normal and ven- 
tricular fluid under increased pressure escaped. This 
internal serous meningitis directed attention to the prob- 
ability that the disease was in the cerebellum, which was 
then explored and the abscess evacuated. 

Pathology. — The pathological changes vary with the 
lesion causing the meningitis. In disease located in the 
temporal bone and c^xtradural abscesses, there is a con- 
gestion of the meninges with an exudation of serum which 
escapes to mingle with the cerebrospinal fluid — a sort 
of collateral edema. In brain abscess an edema of the 
surrounding brain substance accounts for symptoms and 
cytological findings. In meningismus upon exploring 
the brain an edema has at times been found; at others, 
nothing to account for the symptoms has been discovered. 

Symptoms. — The symptoms are very much the same as 
in the early stages of the purulent form. Pain is the 
predominant one, although some fever may be present. 
There may also be stiffness of the neck and increased 
reflexes with photophobia. 

Diagnosis. — ^The diagnosis is made by lumbar puncture. 
If this show^s a sterile fluid under pressure with no marked 
leukocytosis, one makes a tentative diagnosis of serous 



MENINGITIS 355 

meningitis. If the patient recovers and at no time was 
the cuhure positive, the diagnosis is justified. In menin- 
gismus or irritation of the brain, the diagnosis is made 
by the fact that the patient recovers from alarming symp- 
toms, which are present at times and for which no suffi- 
cient pathological basis could be determined. It is well 
to state that meningismus is a name given to symptoms 
resembling meningitis, the cause of which is unknown, the 
word being more or less a ''cloak for ignorance.'' It is 
hoped that it will become obsolete, as it bids fah to do. 

Prognosis. — ^The prognosis as compared with the puru- 
lent form is good. jNIany patients get well. Nevertheless 
it may assume the purulent form, when it is usually fatal. 
As brain abscess may be the cause, the prognosis assumes 
gravity on that account. 

Treatment. — The treatment of serous meningitis is first 
to remove, if possible, the cause. Disease in the tem- 
poral bone should be properly dealt with. A mastoid 
operation or the removal of an oft'ending lab^Tinth may 
result in cm-e. Lumbar puncture may relieve the increased 
intracranial pressure or it may be necessary to accomplish 
this by a decompression operation. It is well to make 
several linear incisions in the dura instead of a crucial 
incision, as these may permit sufiicient drainage to relieve 
tension and result in less brain hernia. If they are insuffi- 
cient, however, the dura may be more freely incised and 
protrusion of the brain allowed. 

Lumbar Puncture. — Lumbar puncture may be per- 
formed with the patient lying upon the side with the 
chest bent well forward upon the abdomen and the 
thighs flexed. This position opens the intervertebral 
spaces. The operation must be done in a thoroughly 
aseptic manner and with a sterile field, both on account 
of the danger of infecting the patient and the necessity 
of keeping the fluid uncontaminated for laboratory 
examination. The site of the puncture may be frozen 
with ethel chloride spray if desired, although the opera- 
tion is usuallv done without it. 



356 COMPLICATIONS OF PURULENT OTITIS MEDIA 

A stiff needle about three inches long is used and 
entered either between the third and fourth or fourth and 
fifth lumbar vertebrae. It is entered slightly to one side 
of the spinous processes and directed so that the point 
of the needle will pierce the intervertebral ligaments 
about in the median line. A sensation of resistance over- 
come is experienced as the needle passes through these 
ligaments and enters the lumbar sac, which will be at a 
depth of from one to two inches in adults, varying with 
the amount of adipose tissue. In children the depth is 
less. 

The fluid is allowed to flow under its own pressure. 
No aspiration should be used nor more than 50 c.c. allowed 
to escape at one time without allowing an interval to 
elapse, as change in intracranial pressure may cause 
unpleasant symptoms. After-eft'ects which at times occur 
are headache, weakness of the lower extremities, sub- 
normal temperature and incontinence of urine, but as 
performed by the aurist upon patients with intracranial 
complications, none of these symptoms are at all common. 

BRAIN ABSCESS. 

Otitic brain abscess occurs as a result of infection and 
breaking dow^n of brain substance, the primary focus 
being a suppurative middle-ear process. 

Causation. — Brain abscess is more often associated with 
chronic purulent otitis media than with the acute form. 
Temporosphenoidal are more common than cerebellar 
abscesses. The condition may arise from dural inflam- 
mation matting the meninges, the infection reaching the 
brain directly, or it may be carried into the cerebral 
substance by thrombophlebitis of the veins or through 
the lymphatics. In these latter instances no adhesions 
are as a rule found in the meninges, while in those caused 
by direct extension the meninges are agglutinated over a 
greater or less area and the abscess is at times discharging 
into the mastoid or middle ear through the stalk formed 



BRAIN ABSCESS 357 

by these matted meninges. The opening of such an 
abscess may be through the tegmen tympani or antri 
or through the cerebellar dura. Infection may occur 
through the internal wall of the sinus in thrombosis of 
this vein, producing cerebellar abscess as a rule, although 
instances are reported of abscess of the cerebrum arising 
from this cause. A very fruitful source of cerebellar 
abscess is suppurative disease of the labjTinth. Probably 
over one-half are produced in this way, the infection 
extending through the internal auditory meatus, the 
aqueductus vestibuli or some defect on the posterior 
surface of the petrous p\Tamid. 

Pathology. — Usually there is but one abscess but at 
times there are more. They are usually located adjacent 
to the infective process causing them, but may at times 
be at some distance, even on the opposite side in some 
reported cases, which are no doubt metastatic in nature. 
Some acute abscesses never form a capsule, while in others 
running a more chronic course a thick capsule may form. 
The capsule is composed of brain tissue infiltrated and 
hardened by inflammatory products and represents 
nature's barrier against the further extension of the pro- 
cess. Causes determining whether or not a capsule will 
be formed are the resistance of the patient and the nature 
of the infection. Neumann has shown that a capsule is 
especially apt to form in diplococcic infections, while it 
is a matter of common observation that they are rarely 
seen in infection w^th the streptococcus. While a capsule 
usually denotes chronicit}^, it does not always do so. 
Some abscesses may become encapsulated in a few weeks. 
In these, however, the walls of the abscess do not seem 
as firm as in the more chronic processes. The pus from 
an abscess cavity is frequently of a very foul odor. Whit- 
ing states (personal communication) that he has never 
observed pus in the mastoid cavity which possessed foul 
odor which did not come from some intracranial compli- 
cation. Usually cultures may be made from the contents 
of an abscess cavity and colonies of bacteria grown, or 



358 COMPLICATIONS OF PURULENT OTITIS MEDIA 

smears may show bacteria in abundance. Occasionally 
the bacteria are dead and will not grow upon cultivation. 
In such an event natural processes are no doubt making 
a more or less successful effort at cure. It is believed by 
some that it is possible for an abscess cavity to become 
filled with cheesy or calcarious matter and lie dormant 
throughout the remainder of the patient's life. Still 
some doubt is felt as to this being the case in instances 
in which it is supposed to have taken place. If, however, 
an abscess ruptures into the mastoid or tympanum the 
possibility of a spontaneous cure cannot be denied. In 
order that this may be ])()ssible the opening should be a 
large one, att'onhng adequate drainage. Some of the cases 
reported, in which spontaneous cure has been believed 
to have taken place, are doubtk'ss either extradural or 
at most subdural coUections of ])us, although no doubt 
some are true brain abscesses. 

Symptoms. — Abscesses ])roduce difl'ereiU symptoms 
during their stage of formation when there is an acute 
cerebritis of greater or less extent than later when a capsule 
may be formed and the ])r()C(^ss more or less latent. The 
symptoms again change in the terminal stage when the 
patient is dying with meningitis or edema of the brain. 
Moreover, a serous meningitis may complicate brain 
abscess and add confusing symptoms. 

In the early stages i)ain is a prominent symptom. It 
is more often present than any other clinical manifesta- 
tion of brain abscess. It may persist throughout the 
disease or until the patient becomes comatose. No deduc- 
tion can be drawn from its situation as to the location 
of the abscess. Experience shows that tem])or()sphenoi(lal 
abscess often occurs with occipital headache, while in 
cerebellar involvement the pain may be in the frontal 
region. It is frequently very intense and prevents the 
patient from sleeping. It may, however, be of a more or 
less remittent type or even absent or so mild that the 
patient does not dwell upon it. 

In the early stages a rise of temperature is usually 



BRAIN ABSCESS 359 

present. The fever, however, is almost always less than 
in sinus thrombosis or in the majority of patients suffering 
from meningitis. The rise of temperature is more or less 
continuous at first but soon, usually in the second or third 
week from the beginning of the cerebral process, the tem- 
perature will drop to subnormal at some time during the 
twenty-four hours. It rises again to between 100° and 102° F. 
as a rule. This is usually regarded to indicate that the 
brain tissue has broken down and an abscess formed, 
accompanied, probably, by increased intracranial pressure. 
As the disease progresses more and more subnormal 
points will be found upon the chart. It is, however, 
uncommon for it to remain below normal throughout 
the twenty-four hours. 

In the early stages the pulse is usually more rapid than 
normal. It is not as a rule as rapid as in meningitis. As 
the temperature becomes subnormal, the pulse as a rule 
becomes slow. It seems to vary with the temperature, 
although it may become slower than normal throughout 
the twenty-four hours. At times it is as low as 45 per 
minute, but a pulse around 60 in a patient suffering with 
a serious complication of middle-ear suppuration should 
suggest brain abscess. It is well to have the pulse and 
temperature taken every two hours, as a subnormal fall 
of either or both of them may direct one's attention to the 
ti'ue nature of the process. 

]\Iental apathy occurs usually about the time the pulse 
and temperature fall, although it is not uncommon before 
that time. The patient seems more or less drowsy and 
answers questions with hesitation. He takes ver}^ little 
interest in what is going on around him. It is evident 
that his mental processes are performed with difficulty. 
As the disease progresses this mental apathy deepens 
into stupor and the patient becomes semicomatose, being 
aroused with difficulty. 

Vomiting is a common symptom and slightly more 
frequently seen in cerebellar than cerebral abscesses. 
One readilv understands this when one considers how 



360 COMPLICATIONS OF PURULENT OTITIS MEDIA 

often a cerebellar abscess is dependent upon a manifest 
purulent labyrinthitis. It is a difficult matter, from a 
study of reported cases, to determine how often the 
vomiting may be due to the labyrinthine condition and 
how often to cerebellar abscess. 

Changes in the eye-grounds usually occur in processes 
below the tentorium and are therefore more common in 
cerebellar than in cerebral abscess, although they are 
very often present in the latter condition. They vary 
from an injection of the retinal vessels to a well-marked 
"choked disk." 

The above symptoms are common to abscess of the 
cerebrum and cerebellum. There are, however, certain 
localizing symptoms which ^\\\ be discussed later. 
Among the other symptoms occasionally seen may be 
mentioned paralysis of the muscles of, the eye, especially 
the external rectus, ptosis, change in the reflexes, various 
paralyses, incontinence of urine and feces, carphologia, 
Cheyne-Stokes respiration, etc., all marking a profound 
disturbance of the central nervous system. As the 
disease passes into the terminal stage there may be the 
symptoms of the purulent meningitis which not infre- 
quently develops at the end. 

Diagnosis. — In the early stage when there is fever and 
increased pulse rate with other symptoms pointing to 
intracranial involvement, it is necessary to rule out 
meningitis. This is done by lumbar puncture and 
examination of the spinal fluid. It should, however, be 
borne in mind that serous meningitis may be caused by 
brain abscess. Once having determined that in all prob- 
ability the lesion is in the brain itself the question arises 
where it should be looked for. In the absence of the 
localizing symptoms it would be necessary to explore 
both the temporosphenoidal lobe and the cerebellum. 
The former w^ould be selected if no localizing symptoms 
pointed elsewhere, both on account of the fact that 
abscesses are more common in this location, and especially 
because this form of brain abscess, unless on the left 



BRAIN ABSCESS 361 

side, does not give localizing symptoms, while those in 
the cerebellum frequently, if not usually, do so. 

Localizing Symptoms. — Most of the cerebral abscesses 
of otitic origin occur in the temporosphenoidal lobe, 
although occasionally one is found in the frontal, parietal 
or occipital lobe. If the process is on the left side, there 
may be aphasia. This is usually of the amnesic variety. 
The patient cannot name any common article such as a 
key, a knife or a pencil which may be shown to him, 
although he knows what it is and may attempt to tell 
what it is used for. Once told the name he repeats it 
with ease. This form of aphasia is due to a subcortical 
lesion in the temporosphenoidal lobe and indicates with 
certainty the location of the abscess. If the lesion 
involves the cortex, there may be word-deafness as well. 
Occasionally, the third left frontal convolution is the 
seat of an abscess. Tkis produces motor aphasia. He 
cannot speak the word to name the article sho\\ai him 
nor can he repeat it after hearmg it spoken. If the lesion 
is on the right side, there is no aphasia or other localizing 
symptoms at present knoT\Ti unless it affects the motor 
area when crossed paralysis is to be expected, although 
this result may doubtless be produced by pressure upon 
the internal capsule. 

Cerebellar Abscess. — In cerebellar abscess the patient 
is very apt to have ataxia and may also have nystagmus. 
When standing on one foot or on both feet with eyes 
closed, or in hopping forward and backward, the patient 
is supposed to have a tendency to fall to the involved 
side, and as a matter of fact usually does so. 

In nystagmus of cerebellar origin, the nystagmus is 
usually toward the involved side. A great deal has been 
written about this nystagmus and in what part of the 
cerebellum the lesion must be to cause it. Wilson^ regards 
it as ataxic in nature and unlike labyrinthine nystagmus; 
it is less behind opaque glasses. If a patient with cere- 

1 Trans. Amer. Otol. Soc, 1915. 



362 COMPLICATIONS OF PURULENT OTITIS MEDIA 

bellar abscess has nystagmus to the same side, which is 
the rule, he falls in the direction of the rapid component 
of his nystagmus. In nystagmus of vestibular origin 
the patient falls in the direction of the slow component 
and also in the direction which the slow component 
assumes if the position of his head is changed. Suppose 
the patient has spontaneous rotatory nystagmus to the 
left of vestibular origin or that it has been produced by 
syringing the right ear with cold water. As the nystag- 
mus is to the left, therefore the quick component is to 
the left, the slow component is toward the right if the 
face is directed forward and the patient falls to the right. 
If the face is directed over the left shoulder, the slow com- 
ponent is forward and the patient falls forward; if the 
face is directed over the right shoulder, the slow com- 
ponent is backward and the patient falls backward. 
In cerebellar abscess whether or not nystagmus is present 
and no matter what its direction if i)resent, the i)atient 
falls to the involved side and the position of the head 
does not change the direction of falling. 

Another symptom which may be i)resent in cerebellar 
disease is overpointing. When j)resent, if the ])atient 
places the forefinger of the hand corresponding to the side 
of the lesion on the finger of the examiner and is then 
requested to raise or lower the finger and bring it back 
to the finger of the examiner he will do so quite accurately 
as long as he guides it by the sense of sight. When he 
closes his eyes, his finger will not return accurately to 
its original position, as in the normal i)erson, but will 
deviate outward, that is, toward the side corresponding 
to the lesion. This may be tried with a wrist motion by 
holding the forearm, with a movement at the elbow-joint 
by holding the arm or by motion at the shoulder-joint. 
Great reliance can be placed on this overpointing, as when 
present it indicates disease of the cerebellum. In horizon- 
tal nystagmus of vestibular origin the patient overpoints 
in the direction of the slow component. 

If nystagmus is present and directed toward the sup- 



BRAIN ABSCESS 363 

posed side of the lesion, and if the labyrinth on this side 
is inactive, as shown by the tests, and if at the same time 
there is slow pulse and subnormal temperature, it is the 
surgeon's duty to explore the cerebellum. This clinical 
picture would be present in cerebellar abscess following a 
suppurative labyrinthitis. 

Another test for ataxia is kno\\aa as adiadokokinesis. 
The patient is requested to alternately pronate and supi- 
nate both hands as rapidly as possible. This he can do 
only in a very deliberate manner on the side of the lesion 
if the test is positive through cerebellar ataxia, while on 
the opposite or normal side he will be able to do it quite 
rapidly. 

Another symptom of cerebellar abscess which occurs 
at times is paralysis of respiration. The breathing ceases 
but the heart continues to beat and will do so for hours 
if artificial respiration is maintained. In numerous 
instances this has occurred at the beginning of an opera- 
tion and has led the surgeon to open the cerebellum and 
evacuate an abscess after which the respiratory movements 
took place normally again. 

Prognosis. — The prognosis of brain abscess is grave. 
]More than one-half of the patients die. Abscesses giving 
the best prognosis are those with a stalk with pus already 
discharging into the mastoid or middle ear, and those 
in which the meninges are matted together, thus lessening 
the danger of meningitis after operation. 

Treatment. — The treatment is the surgical evacuation 
of the abscess and maintenance of drainage until the 
abscess cavity heals. 

Operation, Cerebral Abscess. — The approach to a tem- 
porosphenoidal abscess may be internal, through the 
roof of the mastoid and tegmen tympani, or external 
through the squama. The statistics of operation by the 
internal route are more favorable on account of the fact 
that this is used to drain abscesses with stalks. 

Internal Approach, — The internal operation is per- 
formed as follows : The dura is exposed by removing the 



364 COMPLICATIONS OF PURULENT OTITIS MEDIA 

inner table over the tegmen of the mastoid and tympanum, 
a radical operation having been previously performed. 
If a fistula is found discharging, it is enlarged, taking care 
not to invade the meninges beyond the point of agglu- 
tinizing adhesions, as infection may cause meningitis. 
A cigarette drain or folded rubber tissue may be inserted. 
If no stalk is found, an incision is made in the dura and a 
brain knife or grooved director inserted into the brain 
substance. The point of entrance of the instrument 
should be on the summit of a convolution and not in a 
sulcus. If the latter situation is selected, the pial vessels 
which are abundant in the sulci will be injured and the 
hemorrhage will obscure the field and render it uncertain 
whether or not a small amount of pus has escaped. For 
the same reason any vessels in the dura are to be avoided 
when making the incisions. If the knife is used, after 
it has entered the brain to a sufficient depth, usually 
about an inch, although in some directions it is safe to 
go farther, it is rotated so that the surfaces of the incision 
are held apart and the pus if present allowed to escape. 
If pus does not come from one puncture, several may be 
made in different directions. As long as the knife or 
grooved director is inserted directly into the brain and 
brought out in the same line, no harm results, but if the 
instrument is moved laterally while in position the brain 
tissue will be broken dow^n and harm result. If the pus 
flow^s, the opening is enlarged and a drain inserted. Noth- 
ing of value will be accomplished, as a rule, by inserting 
the finger or encephaloscope. Once the abscess is opened 
and drainage is established the surgeon's duty is simply 
to see that it is properly maintained. 

External Approach, — In exploring the brain by the 
external route an incision is made from the mastoid inci- 
sion upward over the squama and the flaps retracted in 
either direction after being elevated from the squama. 
An opening is made with the large gouge and enlarged 
with the rongeur. A small dural incision is made, as a 
large one will result in the production of a larger brain 



BRAIN ABSCESS 365 

hernia during the heahng process. The brain is explored 
as in the internal route. Fig. 115 shows the bone removed 
as in the two operations. The lower part over the mastoid 
and middle ear for the internal operation, while the upper 
part in the squama for the external operation. 




Fig. 115. — Operation for temporosphenoidal abscess; also subtem- 
poral decompression. The shaded portion of the exposed dura is part 
of the floor of the middle fossa. 



Combined Operation. — It is frequently a good plan to 
make the exploration at the junction of these two on the 
external and inferior border of the temporosphenoidal 
lobe. This is much more convenient and many suc- 
cessful operations have been done in this manner. One 
is then able to direct the exploring instrument in any 
direction desired. 

If the abscess is located in the motor area for speech, 
the bone removal may be continued forward and the 
abscess evacuated, or an incision may be made directly 
over this area, the bone removed and the brain explored. 



366 COMPLICATIONS OF PURULENT OTITIS MEDIA 

The same may be done if the abscess is in the cortical 
center for the face, arm or leg muscles. But these abscesses 
are very rare as complications of middle-ear suppuration. 
Operation for Cerebellar Abscess. — In the cerebellar 
operations there are also two routes; one anterior and 
internal to the sinus and the other posterior to the sinus 
through the occipital bone. If the abscess has followed 
sinus thrombosis, it may very conveniently be opened 
through the inner wall of the sinus. The anterior opera- 
tion may be very difficult if the sinus is far forward, as 




Fig. 116. — Trautman's triangle. The shaded portion is the lateral sinus. 



one then has very little room in which to work. The 
statistics of cerebellar abscess show that the mortality 
is less in drainage by this approach, mainly because 
abscesses with stalks are found discharging into the 
mastoid through this route. 

Antero-internal Approach. — The first step is to expose 
the dura in Trautman's triangle (Fig. 116). The base 
of this triangle is the internal anterior border of the 
lateral sinus which is partially shown as the shaded por- 
tion of the dura in Fig. 116, the upper border is the 
inner table or dura of the middle cranial fossa, its lower 



BRAIN ABSCESS 



367 



border being the lower limits of the mastoid, while its 
apex is inward at the posterior semicircular canal. If 
there is a stalk to the abscess, it is treated in the same 
manner as in the internal operation for temporosphenoidal 
abscess. If not, the cerebellum is explored through a 
small dural incision. The knife may be passed inward 
along the posterior border of the petrous pyramid, and in 
other directions if pus is not evacuated from this location. 




Fig. 117.- 



-Posterior operation for cerebellar abscess, 
location of sinus. 



Dotted lines show 



Posterior Approach. — If the sinus is well forward or as 
a matter of election, the posterior route may be used. 
A large flap of skin and muscle is turned down, making the 
incision from the mastoid wound backward toward the 
external occipital protuberance, but before reaching this 
landmark turning downward. This large flap is separated 
from the bone and an opening made, thus exposing the 
dura over an area from one to two inches in diameter 
(Fig. 117). This should reach forward nearly to the 
lateral sinus. Most aural surgeons begin this with the 



368 COMPLICATIONS OF PURULENT OTITIS MEDIA 

gouge and complete it with the rongeur, but a trephine 
may be used if desired, although the bone is usually not 
very thick in this region. A small dural incision is made 
and the cerebellum explored. It is necessary to bear in 
mind, while exploring backward and downward, that 
this field is much nearer the fourth ventricle than when 
operating anterior to the sinus, and the instrument should 
not be passed over an inch in this direction. 

After the abscess heals, if the patient recovers, the 
flap may be returned to its position by a plastic operation 
and be very convenient in the treatment of brain hernia, 
as moving a flap of skin and subcutaneous tissue is often 
a successful way to treat this pomplication of the healing 
of brain wounds. 

Ajter'treatment. — Tn the after-treatment the drain may 
be shortened from day to day as the abscess cavity 
fills up. Retention of the pus should be guarded against. 
At times a patient fails to recover on accoimt of a second 
abscess which was not drained at the original operation. 
These are to be sought and opened if possible. 



FACIAL PARALYSIS. 

Facial paralysis of otitic origin may occur during the 
course of a suppurative middle-ear process, or as the 
result of injury during operative procedures, or may first 
appear during the healing process subsequent to such 
intervention. 

Pathology. — ^The facial nerve occupies a closed canal 
from the internal auditory meatus to its emergence at 
the stylomastoid foramen. Throughout the greater part 
of this canal it is in intimate relation with the tympanum 
and mastoid. Suppurative processes in these parts not 
infrequently extend to the nerve, producing a neuritis 
with loss of function. At times there is a dehiscence in 
the Fallopian canal in its tympanic part, through which 
an infective process readily gains access to the nerve. 



FACIAL PARALYSIS 369 

Symptoms.— In a gradually developing facial paralysis 
there first appears a weakening of the muscles of the face. 




Fig. 118. — Facial paralysis. Attempting to close the eyes. (Jelliffe.) 




Fig. 119. — Facial paralysis. Attempting to show the teeth. (JeUiffc ) 
24 



370 COMPLICATIONS OF PURULENT OTITIS MEDIA 

The patient cannot close the eye tightly and with the 
same force as upon the opposite side, or the movements 
of the muscles about the mouth on the involved side are 
not so free. He cannot expose his teeth as much on this 
side as on the other. He may still be able to whistle but 
does so with difficulty. As the paralysis deepens and 
finally becomes complete, he will be unable to close his 
eye (Fig. 118) but in the attempt to do so rolls the cornea 
beneath the upper lid. He loses the ability to move the 
angle of the mouth and consequently cannot show his 
teeth (Fig. 119). Whistling becomes impossible and food 
may collect between the cheeks and the teeth, producing 
difficulty during mastication. 

Chorda Tympani. — If the lesion causing the facial 
paralysis is in the T'allopian canal, the chorda tympani 
is involved also. This causes loss of taste sense on the 
anterior two-thirds of the tongue. While there is con- 
siderable variation in the acuity of perception of the 
various sapid substances on the different parts of the 
gustatory surface, still in testing taste perception a solu- 
tion of sufficient strength is used to enable the patient, 
if normal, to recognize the taste if applied to any part 
of this surface. If applied to the anterior two-thirds of 
the tongue, a strong solution of quinine sulphate is recog- 
nized as bitter, a 50 per cent, solution of sodium chloride 
produces the sensation of salt, simple syrup appears 
sweet, and a 25 per cent, solution of tartaric acid is 
recognized as sour. In facial paralysis, if the lesion is 
located in the geniculate ganglion or between it and the 
stylomastoid foramen, or even contiguous to this foramen, 
the patient becomes unable to appreciate these primary 
tastes. 

Maimer of Making Tests. — It is found that if a patient 
is requested to protrude his tongue and one of the solu- 
tions is applied, with a cotton-tipped applicator, to its 
anterior two-thirds and he i^ then asked to state the 
sensation, in attempting to speak he will withdraw his 
tongue, spreading the solution over other parts of the 



FACIAL PARALYSIS 371 

gustatory surface. The experiment thus becomes of 
no value. To obviate this a chart is printed with the 
words, sour, salty, bitter, sweet, and after the solution is 
applied the patient is requested to point to the experienced 
sensation without withdi^awing his tongue. One thus 
ascertains whether or not he recognizes the taste of the 
solution applied to the anterior two-thirds of his tongue 
and thus forms an opinion as to the integrity of the chorda 
tympani. 

Diagnosis. — The diagnosis of facial paralysis offers no 
difficulties. One is able to see at a glance that the muscles 
of the face do not contract normally. It is important to 
determine the location of the lesion if possible, not only 
as bearmg upon the prognosis of the paralysis but also 
as having an influence upon the treatment adopted for 
the process of which it is a complication. The occurrence 
of facial paralysis may determine the adoption of opera- 
tive interference in a given case. There is, however, no 
reason why a patient with a suppurative middle-ear 
process may not have facial paralysis from involvement 
of the nerve in the neck. So before relying upon facial 
paralysis as a symptom which indicates operation, a test 
of taste perception of the anterior two-thirds of the 
tongue should be made. The T\Titer has observed two 
patients with suppurative middle-ear disease and facial 
paralysis, upon whom the mastoid operation would have 
been done, but for the fact that the taste sense was not 
lost on the anterior two-thirds of the tongue. The chorda 
tympani thus being intact, the facial paralysis was not 
due to the suppiu^ative process, the mastoid was not 
opened and recovery without operation took place. 
If the tests show involvement of the chorda tympani, 
the facial paralysis is not necessarily due to the middle-ear 
process, but no means are known to determine that this 
is not the case. Tests show that there is loss of taste in 
about 10 per cent, of acute and nearly 50 per cent, of 
chronic middle-ear suppurations independent of facial 
paralysis. 



372 COMPLICATIONS OF PURULENT OTITIS MEDIA 

Prognosis. — ^Those paralyses which develop before 
operation usually offer a good prognosis. Occasionally 
one develops with labyrinthine involvement and is due 
to sequestration of a portion of the Fallopian canal. In 
this case the outlook as to the cure of the paralysis is not 
good. Paralyses which are present at the conclusion of 
an operation are usually due to some injury of the nerve 
and do not offer a good prognosis. The palsy may exist 
at the end of the operation and may not be due to injury 
inflicted by the instruments of the surgeon, and at times 
a patient with this condition recovers the action of the 
facial muscles to a large extent. Nevertheless, when 
facial paralysis is present at the end of an operation, more 
or less permanent impairment of function may be expected. 
Those paralyses which develop subsequent to operation 
oft'er a good prognosis, unless (hie to sequestration of the 
labyrinth. 

Treatment. — If the facial paralysis ai:)pears before 
operative interference and is due to the i)urulent otitis 
media or mastoiditis, it is usually an indication for an 
operation. Taken alone without any indication that 
the process which it accompanies is serious, it does not 
demand operation either for the cure of the paralysis or 
of the process of which it is a complication. Still, one is 
so accustomed to see facial palsy only in processes of a 
serious nature that he is usually uneasy until operation 
is performed. The paralysis, if not due to injury of the 
nerve, usually begins to get well in about six weeks. 
Meanwhile, the nutrition of the muscles may be main- 
tained by the daily use of electricity and massage. This 
is especially necessary when recovery does not take place 
so promptly. 

Indications for Anastomosis. — When due to injury 
the advisability of forming an anastomosis between 
the facial and the hypoglossal or spinal accessory is to 
be considered. It is difficult to say just how soon after 
the occurrence of the injury this should be done. In a 
patient at the New York Eye and Ear Infirmary, whose 



FACIAL PARALYSIS 373 

paralysis was evident on his emergence from the anes- 
thetic, total facial paralysis persisted for nearly two 
years, when improvement began and continued until 
the facial muscles acted in almost a normal manner. The 
final condition of this patient was perhaps much better 
than it would have been had an anastomosis been made. 
Experience has show^n that when one waits too long after 
the paralysis has occurred, the result is not so good as 
in an earlier operation. After the reaction of degeneration 
is present for a certain length of time, the nerve seems to 
become softer and is not so easily handled. If the operator 
is certain that the nerve is completely divided, he is not 
justified in waiting so long as when he believes that only 
partial division has taken place. In the latter case it is 
probable that the total paralysis is due to an inflammation 
of the uninjured part of the nerve, and partial, or at 
times practically complete, return of function may be 
expected. 

Anastomosis, — The first anastomoses were made be- 
tween the spinal accessory and the facial, either an 
end-to-end union or implantation of a part of the spinal 
accessory into the facial. In the former case paralysis of 
the sternomastoid and part of the trapezius takes place; 
in the latter after healing has occurred there may be 
involuntary movements of the shoulder when the patient 
attempts to move the face. For this reason, implantation 
of the facial into the hypoglossal has become the opera- 
tion usually selected. An incision is made along the 
anterior border of the mastoid immediately behind the 
auricle and extending downward along the anterior 
border of the sternomastoid which is exposed and drawn 
backward. The posterior belly of the digastric is then 
located. The styloid process may be felt with the finger. 
The nerve emerges from the bone at the base of this 
process and passes superficial to it. It is well to remove 
the bone over the descending limb of the Fallopian canal 
and carefully remove the nerve after cutting it as high 
as possible. This gives a longer stump and allows the 



374 COMPLICATIONS OF PURULENT OTITIS MEDIA 

connection to be made with the hypoglossal without 
tension. The hypoglossal is now sought, the guide being 
the transverse process of the atlas. The occipital artery 
may be felt, and if traced downward to its origin from the 
carotid, the nerve may be located winding around the 
artery, but the anastomosis is made above this point. 
The jugular vein also comes into view and is to be drawn 
backward, w^hen two nerve cords are exposed, the pneumo- 
gastric and the hypoglossal. By electrical stimulation 
the hypoglossal is selected. This is recognized by the 
contraction of the muscles of the tongue and thyroid 
group. A slit is made in the hypoglossal and into this 
slit the stump of the facial, previously trimmed to a i)oint, 
is inserted as follows: two stitches are taken in the facial 
stump a short distance from the end, one on either side, 
these sutures are caught in the margins of the slit in the 
hypoglossal and tied as the facial stump is inserted into 
the slit. Cargyle membrane is ])laced around the union 
to prevent scar formation, and the wound closed. The 
hypoglossal ])aralysis ])asses away more or less completely. 
The patient is submitted to various educational exercises 
to accustom him to the use of the new nerve path. 

ABDUCENS PARALYSIS. 

Paralysis of the external rectus is at times associated 
with and due to suppurative middle-ear disease. The 
author^ collected all of the cases reported in the literature 
of the subject, a total of 88, to w^hich he added 6 cases, 
making a total of 94. Since that time numerous cases 
have been reported by various observers. 

Anatomy.^ — The anatomical arrangement of the sixth 
nerve renders it susceptible to involvement in the puru- 
lent diseases affecting the temporal bone. From a point 
where the nerve enters a perforation in the dura, external 
to the inferior petrosal sinus, until it comes in relation to 

1 Annals of Otology, etc., September, 1910. 



ABDUCENS PARALYSIS 



375 



the branches of the third nerve on the external wall of 
the cavernous sinus, it is contained in a fibrous canal 
called by Gradenigo, Dorello's canal, from the anatomist 
who first described it. As it passes forward it is in rela- 
tion wdth the inferior petrosal sinus which lies imme- 
diately internal to it, then it passes beneath a bridge 
which is shown cut in Fig. 120. This bridge is formed 



3 




Fig. 120. — Relations of the sixth nerve. 1, sixth nerve; 2, fifth nerve; 
3, Gasserian gangUon on fifth nerve; 4, internal carotid artery; 5, inferior 
petrosal sinus; 6, superior petrosal sinus. The petrosphenoidal ligament 
is shown cut in the figure. 

by the petrosphenoidal ligament which extends from the 
internal end of the superoposterior border of the petrous 
pyramid to the base of the posterior clinoid process. 
Beneath this bridge and slightly anterior to it the nerve 
lies upon the extreme end of the apex of the petrous 
portion of the temporal bone. Immediately after passing 



376 COMPLICATIONS OF PURULENT OTITIS MEDIA 

the bridge it is in relation above with the superior petrosal 
sinus and externally with Meckel's cave which contains 
the Gasserian ganglion. From this point forward it lies 
on the outer wall of the cavernous sinus, emerging at its 
anterior end to enter the orbit through the sphenoidal 
fissure. 

Pathology. — It is evident that thickening of the fibrous 
tissue which encloses the nerve will result in pressure 
upon, and interference with, the function of the nerve. 
1 his may take place through inflammatory processes in 
the posterior fossa. In this event the swelling may be 
of the dura at its point of entrance, as in large extradural 
abscesses in the ])()steri()r fossa, or from thickening of the 
tissue around the nerve, as in thrombophlebitis of the 
inferior petrosal sinus. Where it lies u])()n the apex of 
the petrous portion any inflammation of the bone which 
thickens the tissue surrounding the nerve leads to abdu- 
cens paralysis. In some ])neTnnatic bones the cells extend 
well into the petrous ])()rti()n, and there is not infrequently 
a large cell immediately at the ti]) adjacent to the nerve 
(Fig. 58). With such a conformation the involvement of 
the mastoid cells and middle ear may extend sufficiently 
to involve this cell also. In doing so the infection may 
take one of the following ])aths: {a) sublabyrinthine, 
extending below the labyrinth and internal auditory 
meatus, as in a patient dying of meningitis, whose case 
was reported by Lombard.^ Auto])sy showed very 
pneumatic bone with pus in the cells of the petrous apex. 
On the opposite side the cells in the apex of the petrous 
portion were large and mercury poured into them 
emerged in the tympanimi; (/;) from the mastoid antrum 
the infection may extend through the subarcuate fossa 
and by involving the chain of cells that sometimes exist 
above the internal auditory meatus, thus reach the 
cells in the petrous apex; {c) along the carotid canal; 
(rf) or by way of a layer of cells extending along the 

1 Annals des Mai. de I'Orcill, etc., 1906, xxxii, 321. 



ABDUCENS PARALYSIS 377 

Eustachian tube. After pus has formed in the petrous 
apex it may break through superiorly, forming an extra- 
dural abscess, or inferiorly escaping posterior to the 
nasopharynx, forming a retropharyngeal abscess. 

Symptoms. — ^There are symptoms of the middle-ear 
process of which the abducens paralysis is but an incident. 
The affection of this muscle is easily made out. As the 
eyes fixed upon the finger follow it outward, the one 
involved does not abduct, thus showing paralysis of the 
external rectus supplied by the sixth nerve. If the 
affection is long-continued convergent squint may exist. 
As the Gasserian ganglion lies adjacent to the cells in 
the petrous apex, it may be simultaneously involved 
with the sixth nerve when the lesion producing the 
paralysis occurs in this location, causing pain in the 
parts supplied by the fifth. This is very marked in some 
patients and the association of severe neuralgic pain 
referred to the region of distribution of the fifth nerve, 
with abducens paralysis and suppurative otitis media, 
is called Gradenigo's triad, from the otologist who first 
described these associated symptoms and recognized 
their significance. 

Diagnosis. — The diagnosis offers no difficulties. If the 
paralysis of the external rectus has occurred with, or 
following upon, a suppuration of the middle ear, it is 
reasonable to suppose that it is in some way related to 
it, unless another cause can be discovered. If in addition 
there are severe neuralgic pains of the brow or face, the 
lesion is in all probability located in the apex of the 
petrous portion. 

Prognosis. — Of the 94 patients, 11 died of meningitis, 
recovery occurred in 67, probable recovery in 5, partial in 
4, no improvement in 1, not stated, 6. 

Treatment. — Involvement of the sixth occurred after 
the mastoid operation in 27 patients, not stated, 7, and 
before in 60. Of these 60 the operation was performed in 
29 with 1 death, 1 persistence of the paralysis, while 
in the remaining 27 the condition of the abducens became 



378 COMPLICATIONS OF PURULENT OTITIS MEDIA 

normal. If a mastoid operation has not previously been 
done, it is no doubt indicated if the patient has acute 
otitis media. If suppuration is chronic, the radical opera- 
tion should be performed. Still it must be remembered 
that patients do recover without operative interference. 
The operation performed by Goris^ demonstrates that 
the region of the ])etrous apex is not beyond surgical 
interference. In this procedure the roof of the external 
auditory canal, tympanum and mastoid are removed, 
thus exposing the dura to the superior semicircular canal. 
From this point in, the dura is separated from the bone 
and held away by si:)atuhe, the petrous tip curetted, or 
an extradural abscess evacuated, (ioris, in the patient 
upon whom he operated, found an extradural abscess 
and with a curette removed a sequestrum from the 
petrous ai)ex. Abscesses in the ])harynx or neck should 
be evacuated either by incision through the mouth or 
by an external route, according to their location or pre- 
ference of the surgeon. Incisions seem to be, as a rule, 
all these abscesses re(|uir(\ 

' Amiiil. di\s Mill, dc TOreilk', etc., xxix, G4. 



CHAPTER XII. 

NON-SUPPURATIVE DISEASES OF THE 
INNER EAR. 

General Considerations. — Diseases of the lab^Tinth and 
eighth nerve, notwithstanding much important work, 
still remain more or less obscure. While the lesions which 
complicate the suppurative inflammations of the middle 
ear and mastoid are becoming better understood, progress 
is made slowly in the knowledge of those diseases of the 
inner ear which do not occur with these processes. One 
reason is that these diseases are perhaps not so common, 
but more important, still, the fact that opportunity of 
examining the temporal bone of patients carefully observed 
during life rarely occurs. 

Causation. — When the perceptive mechanism is involved 
the deafness is usually quite marked. ^Nlany of these 
patients give no history of attacks of any kind to which 
the deafness may be attributed. They may or may not 
give a family history of deafness. ^Nlany of them are 
doubtless subjects of otosclerosis. The Wassermann 
should always be taken and throws light on the causation 
at times. Some patients give a history of having impair- 
ment of hearing or total deafness following some general 
disease. ]Many of these seem to be able to produce sound- 
perception mechanism disease without apparently involv- 
ing the middle ear. Epidemic cerebrospinal meningitis, 
scarlatina, measles, diphtheria, mumps, smallpox, typhoid 
fever, and others, are capable of causing such processes. 

The eighth nerve and lab\Tinth are affected by many 
drugs. Quinine, salicylic acid, arsenic, lead, alcohol and 
tobacco, are able to produce some change in these struc- 
tures which cause symptoms. Usually the change is but 



380 NONSUPPURATIVE DISEASES OF INNER EAR 

temporary and passes away, but this is not always the 
case. One sees from time to time patients who attribute 
their deafness to quinine or saHcyUc acid. Usually one 
is able to prove that this belief is without foundation by 
finding that the lesion is in the sound-conducting mech- 
anism, but occasionally it is found to be in the receptive 
mechanism when one feels that there may be some basis 
for their belief. 

Symptoms. — The symptoms may be divided into two 
classes: Those which arise from disease of the perceptive 
mechanism, namely, impairment of hearing and tinnitus, 
and those which arise from disturbance of the static 
mechanism, namely, nvstagmus, vertigo, nausea and 
vomiting and unsteady gait. These two classes of symp- 
toms may occur together in the same patient or impair- 
ment of hearing may be present, the j)atient never having 
had symptoms referable to the static labyrintli or vestibu- 
lar nerve, in which event the static api)aratus may give 
the normal reactions, or as is usually the case, they may 
be negative. The absence of caloric and a negative rota- 
tion reaction indicate disease of the static labyrinth or 
the vestibular branch of the eighth nerve. In order 
that the nystagmus, vertigo, etc., may be produced, it is 
believed to be necessary that the lesion producing them 
should develop in a more or less rapid maimer. The 
number of patients in whom the caloric and rotation 
tests are negative and who give no history of having had 
vertigo, is considerable. They encourage the belief that 
if the loss of the static function is sufficiently gradual, the 
opposite labyrinth may be able to accustom itself to this 
loss without at any time manifesthig symptoms of dis- 
harmony. If both sides are involved equally and make 
the same progression toward loss of function, it is apparent 
that no disharmony of the two static mechanisms will 
occur, but that other parts of the nervous system will, 
so far as they are able, take upon themselves the functions 
which have been lost. 

In diseases of the cochlea which have produced deafness, 



SYMPTOMS 381 

the bone conduction with a 256 D. V. fork should be 
about one-half of air conduction. If this should be the 
case in a patient under forty-five years of age, who had 
marked impairment of hearing, the lesion could with 
certainty be located in the perceiving mechanism. As 
the air conduction would be very much reduced on 
account of the patient^s deafness, it follows that the bone 
conduction, which is | A. C, would be reduced also 
(B. C — ). In diseases of the cochlear branch of the 
eighth, it is believed that the ratio of air and bone conduc- 
tion becomes still further changed, so that B. C. becomes 
less than one-half of A. C. It is certain that it does in 
syphilitic affections of the nerve and it is probable that 
it does in other conditions also, although too much reliance 
cannot at present be placed upon it in attempting to sepa- 
rate lesions in the cochlea from those in the nerve. 

If in marked deafness the lower-tone limit is normal, 
it merely is evidence that the lesion is in the sound-per- 
ceiving mechanism, but if at the same time the upper- 
tone limit is reduced, it indicates that the lesion involves 
the labyrinth, although the nerve central to the cochlea 
may at the same time be involved. The cochlea contains 
the mechanism b}^ which the tones of the musical scale 
are analyzed, so if the perceptive apparatus fails to pick 
up and register tones of a certain pitch while others are 
heard, the lesion must be in the cochlea. Thus if the 
upper tones cannot be perceived, or if there is a gap in 
the musical scale in which the sonorous vibrations are 
not registered, or if deafness for a greater part of the 
musical scale exists, while tones of a certain pitch m one 
or more parts of the musical scale can be heard, the 
lesion must be in the labyrinth. If one cannot find these 
tone islands, tone gaps or lowering of the upper tone 
limit, he is not justified in assuming from this fact alone 
that the lesion is not in the cochlea, as instances are 
common where disease affects all parts equally of the 
organ which picks up and registers the notes of the 
musical scale, that is, the organ of Corti. 



382 NONSUPPURATIVE DISEASES OF INNER EAR 

The upper-tone limit is lowered in those processes in 
the labyrinth which are secondary to non-suppurative 
disease in the middle ear, although it is probable that 
many of these which are considered to be due to chronic 
catarrhal otitis media are really cases of otosclerosis. 

Tinnitus in some instances is a prominent s\'mptom. 
If the tinnitus is due to a stimulation of the acoustic 
nerve or apparatus, one can readily understand why it 
would be present while the lesion is being formed and the 
deafness is increasing, but one would exi)cct when the 
patient became absolutely deaf it would cease. As a 
matter of fact it often does so, but instances are by no 
means rare in which the sul)jective noises have persisted 
long after deafness has become absolute. 

If every patient presenting with impairment of hearing, 
with or without tinnitus, and in whom no snppnrative 
process is found, were to have a careful examination to 
determine the bone conduction and tone limits, it wotlld 
be discovered that many ])atients are being treated as 
chronic catarrhal otitis media who hnvc some lesion of 
the sound-perceiving mechanism. Tlic diagnosis of 
O. M. C. C. should never be made withont tliis examina- 
tion. It is, however, much neglected in many of the 
large clinics. I nless the ])atient c()mj)hiins of vertigo 
or some symptom which directs attention to the hiby- 
rinth, the impairment of hearing is carelessly attributed to 
disease of the conducting mechanism and the i)atient 
treated for chronic catarrhal otitis media. In i)ri\'ate 
practice this is naturally not so apt to occur. 

Meniere's Symptom-complex, — In LSOl Meniere reported 
a case of labyrinthine hemorrhage ; the patient, a girl aged 
sixteen years, who ''caught cold" while driving and 
suffered an attack, the symptoms being tinnitus, deafness, 
vertigo, vomiting and unsteady gait. Death occurred 
five days later and the postmortem revealed a red plastic 
exudate in the semicircular canals extending into the 
vestibule. These symptoms having such a definite patho- 
logical basis naturally attracted attention at a time when 



LABYRIXTHIXE HEMORRHAGE 383 

knowledge of diseases of the labyrinth was meagre, and 
for many years a patient presenting a sudden attack of 
deafness, vertigo, vomiting and staggering gait ^as 
supposed to have labyrinthine apoplexy, or "'Meniere's 
disease.'' As it became known that the same s^TQptoms 
occmred without labyrinthine hemorrhage, may in fact 
be due to many different lesions of the lab^Tinth or eighth 
nerve, these clinical manifestations came to be called 
Meniere's symptom-complex. Any lesion which produces 
an imbalance of the static mechanism, eithc^r by stimu- 
lating one side, or what amounts to the same thing, b>' 
cutting out the impulses which normally emanate from 
the other static lab^Tinth, will result in the production 
of this s\TQptom-complex, the deafness being caused by 
the cochlear involvement. The feeling is quite general 
among otologists that the use of the term is not conducive 
to scientific accmacy. One very important s^Tnptom 
which was omitted from the descriptions of the symptom- 
complex is nystagmus. This is probably never absent 
and if the term is continued in use it must be added. It 
is better perhaps not to use the term at all, but to apply 
Meniere's name, if it must be used, to labATinthine 
hemorrhage. 

LABYRINTHINE HEMORRHAGE ^MENIERE'S 
DISEASED 

Red blood cells or even small hemorrhages may be 
present in the lab\Tinth in the severe form of serous or 
in purulent labyrinthitis, but they constitute but a small 
part of the process and in themselves do not noticeably 
affect the symptomatology. It is to those hemorrhages 
which occm without infection and are the cause of symp- 
toms that the name is applied. 

Etiology. — Small hemorrhages may occur in the general 
infectious diseases or in the acute middle-ear inflam- 
mations, but as a rule some change in the bloodvessels 
or in the blood itself acts as a cause. Thus various con- 



384 NONSUPPURATIVE DISEASES OF INNER EAR 

stitutional diseases predispose the patient to local hemor- 
rhages. Insofar as the labyrinth is concerned, leukemia 
seems to be the chief of these. Perhaps the reason this 
is apparently so is that autopsies are more frequent in 
patients with this disease than in those who have lab>Tin- 
thine hemorrhage as a result of some less fatal malady. 
Alexander^ claims that Meniere's original case was 
leukemic. Gruber^ reports the findings in an autopsy in 
a syphilitic patient who died of typhus in whom labyrin- 
thine hemorrhage was present. 

Pathology. — The lesion is the rupture of a bloodvessel 
supplying the membranous labyrinth, which gives rise 
to an extravasation of greater or less extent. It is rational 
to suppose that the size and location of the clot, as well 
as the amount of destruction or displacement of the 
delicate intralabyrinthine structures, will have an influence 
not only upon the symptoms but also on the healing 
process. Hemorrhage would necessarily be limited by 
rise of labyrinthine pressure caused l)y it. As the extrav- 
asation is taking place, various distortions may occur. 
Thus, if the hemorrhage is into the cavity of the mem- 
branous labyrinth it can make very little provision for 
increased pressure. It has been seen that the mechanism 
for regulating the pressure of the endolymph is the ductus 
endolymphaticus, which is a bull) containing endolymph 
which projects into the cranial cavity through the aque- 
ductus vestibuli. This would be inadequate to make 
provision for a hemorrhage of any considerable (relatively) 
size so there would be distortion at other locations where 
this is possible. This distention in the cochlear duct 
results in disturbance of the delicate structures contained 
therein, which are concerned with hearing, perhaps also 
rupture of Reisner's membrane which is the most vul- 
nerable part of this duct. This would account for the 
deafness in Meniere's patient in whom the exudate was 



1 Zeitschrift fiir Ohrenheilk., 1906. 
2Lehrbuch der Ohrenheilk., 2 Aufl., 1881. 



LABYRINTHINE HEMORRHAGE 385 

limited to the semicircular canals and vestibule. As the 
extravasation is absorbed very slight changes may be 
left, or adhesions between and distortions of the various 
intralabyrinthine structures with the formation of vary- 
ing amounts of fibrous or even osseous tissue may result. 

Symptoms. — ^The symptoms are tinnitus, deafness, 
vertigo, nausea and vomiting, staggering gait and nys- 
tagmus. Usually the hearing is normal before the first 
attack. This is insisted upon by many authorities. 
There seems no good reason, however, why an attack of 
labyrinthine hemorrhage should not occur in a patient 
the subject of a catarrhal middle-ear process. After 
the first attack more or less deafness may be expected. 
All of these symptoms may not be present in every 
patient and there is considerable variation in the severity 
also. After the attack the symptoms may disappear in 
a few days, leaving the patient totally deaf. This occurs 
if the hemorrhage is sufficient to destroy the intralaby- 
rinthine structures. In such a patient the caloric and 
rotation tests are negative. It is more common for the 
symptoms to disappear gradually, the patient having 
nystagmus and more or less vertigo for some time. Or 
these may continue in a varying degree of severity until 
subsequent attacks occur. The condition of some of 
these patients becomes exceedingly distressful. If they 
turn around quickly or stoop over, vertigo ensues and the 
uncertainty as to the occurrence of the next serious 
attack renders life all but unbearable. 

Diagnosis. — ^There is no certain way of ascertaining 
that the symptoms are due to a labyrinthine hemorrhage. 
One infers that the lesion is in the labyrinth from the 
absence of involvement of the facial which would be 
expected to occur if the lesion was in the internal auditory 
meatus, and from the absence of symptoms referable to 
implication of the nerves in relation with the eighth at the 
base of the brain. The sudden onset of the symptoms in 
an apparently normal middle ear is also a point in favor 
of apoplexy of the labyrinth. 
25 



386 NONSUPPURATIVE DISEASES OF INNER EAR 

Prognosis. — The patient may have but one attack. 
This is more apt to be the case if the labyrinthine func- 
tions are ablated. If recovery with some function occurs, 
more attacks may be expected, although they may not occur. 

Treatment. — During the attack the patient is put to 
bed. The head, to which cold applications are made, is 
slightly elevated. A laxative may be administered and 
full doses of the bromides given. As the attack passes 
off the iodides may be associated with the bromides. 
Pilocarpine will be found of value in some patients. It 
is administered as suggested under Perilabyrinthitis. If 
the vertigo between the attacks is severe and there 
seems no prospect of relief otherwise, the labyrinth may 
be destroyed. It must be explained to the patient that 
he will be totally deaf but that the prospect of relief from 
his vertigo is good, although not absolutely certain. 
The decision is to be left with him. The operation is to 
be performed about the same as in drainage of the laby- 
rinth. The object is to destroy the cristae ampullae, so 
the cochlea need not be molested, but the canal system 
and especially the ampulla of the canals must be opened 
and the nerve tissue as far as possible destroyed. 

LEUKEMIC DISEASE OF THE INNER EAR. 

Leukemic involvement of the labyrinth, while not so 
common as that of the retina, takes place in about 10 per 
cent, of the patients. The lesion in the labyrinth may 
be a hemorrhage or the exudation of lymph cells; as 
these become absorbed, new connective tissue may form 
or an osseous deposit occur, more or less obliterating the 
labyrinthine spaces. Exudation of lymph cells or hemor- 
rhage may occur in the internal auditory meatus affecting 
the eighth nerve, perhaps also the seventh, or it may be 
in the middle ear or Eustachian tube. 

Leukemic affections of the labyrinth and eighth nerve 
either begin suddenly with deafness, nystagmus and 
vertigo or the impairment of hearing may occur alone 



ANEMIA OF THE LABYRINTH 387 

and get worse rapidly, leading to total deafness in the 
course of a few weeks or months. If the lesion is in the 
middle ear and the sound-perceiving mechanism is intact, 
there may be pain, but the deafness is not so profound, 
nor will there be present the nystagmus or vertigo. The 
prognosis both as to the aural condition and the general 
disease is bad. If the middle ear is involved and tension 
is marked, an incision of the drum membrane is indicated. 
The treatment otherwise is the same as in labyrinthine 
hemorrhage, except that an operation is not to be con- 
sidered. 

ANEMIA OF THE LABYRINTH. 

Anemia of the labyrinth is usually a part of a general 
anemia but it may be of a more or less local nature. 

Causation. — Symptoms referable to it are usually caused 
by the sudden loss of a large quantity of blood, pernicious 
anemia, or after severe acute diseases, less often in the 
anemias of chronic disease. Processes causing local 
anemia are those which produce any interference with the 
flow of blood through the internal auditory artery, which 
constitutes practically the only blood supply of the 
labyrinth. Conditions which have been knoTvoi to produce 
this result are : aneurysm of the basilar artery, neoplasms 
growing from the dura in the internal auditory meatus 
or in the immediate neighborhood, bony outgrowths in 
this canal, or thickening of the vessel in arteriosclerotic 
processes. It is probable that the latter condition is 
often a causative factor in the deafness of old age. An 
embolism, if sterile, might cause anemia, especially if small 
enough to reach some of the branches of the internal 
auditory artery so that some collateral circulation could 
take place within the labyrinth. Angioneurotic pro- 
cesses may be so localized as to effect the labyrinthine 
circulation. 

Symptoms. — If the onset of the anemic condition in 
the labyrinth is acute, there will be sudden deafness which 
is more or less pronounced, perhaps tinnitus, vertigo and 



388 NONSUPPURATIVE DISEASES OF INNER EAR 

vomiting, accompanied, of course, by the symptoms of 
the disease causing the anemia. The symptoms very 
much resemble seasickness. In the angioneurotic form, 
which, presumably, would be localized to one side, there 
will be nystagmus in addition to the deafness, tinnitus 
and vertigo. These symptoms recede with the disap- 
pearance of the anemia, leaving the labyrinth intact with 
return to normal function. If the anemia is due to 
chronic general causes or is the result of some slowly 
devel()i)ing interference with the circulation in the internal 
auditory artery, ])r()gressivc tinnitus and deafness are 
usually the main sym])toms, although vertigo may occur. 
In labyrinthine anemia the deafness and tinnitus may l)e 
more pronounced in the erect than in the recuml)ent 
posture, due no doubt to change in the local blood sui)])ly. 

Diagnosis.— The diagnosis in the acute form associated 
with general anemia offers no difficulty. The patient has 
his general symj^toms plus those attrilnitable to the 
labyrinth. In the chronic form, the progressive impair- 
ment of hearing, which tests show to be due to a lesion 
of the perceptive mechanism, associated with tinnitus, 
are common to so many conditions that the diagnosis 
may be difficult. One must be contented with assuming 
that labyrinthine anemia accounts in the best manner 
for the symi)toms when considered with the manifesta- 
tions of the disease of which it is but a part. 

Prognosis. — When occurring with acute anemia or in 
the angioneurotic form, the prognosis is good insofar as 
the labyrinthine condition is concerned. Recovery 
with return of function may be expected. In the chronic 
forms the lesion is of such a nature that recovery cannot 
be expected. 

Treatment.— The treatment is to relieve the general 
anemia of which it is a part. In the angioneurotic patients 
the bromides and quinine are of value. Bromides may be 
given for the tinnitus. Amyl nitrite has been suggested. 
Patients have been known to obtain relief from the tin- 
nitus and other subjective symptoms by inhaling a few drops. 



HYPEREMIA OF THE LABYRINTH 389 

HYPEREMIA OF THE LABYRINTH. 

Lab^Tinthine symptoms may be caused by hyperemia. 
This occurs in the early stage of serous and suppurative 
labyrinthitis, but outside of these diseases a hyperemia 
may exist which is not a part of an inflammatory process. 

Causation. — In postmortem examinations in patients 
having acute otitis media occurring in the course of 
scarlatina, diphtheria and typhoid fever, hyperemia of the 
lab\Tinth has been found, so any of the acute infectious 
diseases may be the cause of the disease under discussion. 
It may also be caused by any condition which interferes 
with the return flow of blood from the brain, as jugular 
resection or tumors in the neck. Tumors in the region 
of the internal auditory meatus by pressing upon the 
veins may also act as a cause. The labyrinthine hyper- 
emia, if long continued, may result in changes, but usually 
does not do so. 

Symptoms. — The sjTuptoms are tinnitus, deafness, 
vertigo and a feeling of fulness in the ears and head. 
These symptoms may exist associated with the clinical 
picture of cerebral hyperemia of which it is but a part. 
The cheeks may be flushed, the auricles red, and at times 
there may be found an increase in the blood supply of the 
fundus of the external auditory meatus. 

Diagnosis. — ^The lab^Tinthine symptoms occurring in 
acute middle-ear processes, while possibly due to this 
condition, should be looked upon with suspicion as being 
much more probably due to some of the inflammatory 
complications which occur in the labyrinth. If there is 
evident cerebral hyperemia and labyrinthine symptoms 
occur and pass away with the subsidence of the condition, 
leaving the organ functionating normally, it is fair to 
assume that the condition affected the labyrinth also. 
It must, however, be borne in mind that hyperemia of 
the brain may produce vertigo, perhaps also tinnitus 
and deafness by involving the eighth or its central con- 
nections. Politzer claims that the diagnosis can only be 



390 NONSUPPURATIVE DISEASES OF INNER EAR 

made when otoscopic examination shows hyperemia of 
the fundus of the external auditory meatus. 

Prognosis. — The prognosis is as a rule good. In fact, 
if permanent change in function is produced, one would 
hesitate before believing that the process had been one 
of hyperemia pure and simple. 

Treatment. — The treatment varies with the causes. 
These should always be found and relieved if possible. 
The patient should be put to bed. The head, to which 
cold applications are applied, elevated. Hot applications 
to the extremities. Calomel followed by a saline may be 
useful. The bromides should be administered in full 
doses. In very severe types local or general abstraction 
of blood may be advisable. 

OTITIS INTERNA. 

Definition. — The term otitis interna may be applied to 
processes which att'ect the hmer ear and are not secondary 
to the purulent middle-ear inflammations. The term is 
not to be considered as indicating the nature of the pro- 
cess, but as a convenient one under which to discuss a 
certain type of case. Patients are continually presenting 
themselves who are profoundly deaf. Functional tests 
locate the lesion in the perceptive apparatus. Examina- 
tion of the drum membrane fails to reveal any change 
which indicates either present or past suppuration. The 
history is that the patient suffered from one of the infec- 
tious diseases upon recovery from which deafness was 
found to be present, or the child had a fever of unknowoi 
nature whi-ch left him deaf. It is possible that in some 
of these patients there was a suppurative middle-ear 
process which left no apparent changes, to which there 
occurred a secondary serous or purulent labyrinthitis, 
which is responsible for the loss of function. Such a pro- 
cess is not, however, in the habit of exhausting itself 
and leave no evidence which can be seen upon inspection 
of the drum membrane. So it is assumed that there was 



OTITIS IXTERXA 391 

an inflammation of the lab^Tinth independent of middle- 
ear involvement or some pathological process m the 
acoustic and vestibular nerves, either m the internal 
auditory meatus or at the base of the brain, to account 
for the symptoms. 

Etiology. — The most common cause of the disease is 
epidemic cerebrospmal meningitis. Durmg the last ten 
years many patients have come to the clinics attributing 
theh deafness to this disease. Followmg the epidemic of 
1904-5, they were especially common. Not mfrequently 
the condition was due to measles, mumps, scarlet fever, 
diphtheria, and less often mfluenza. At times as far as 
can be ascertained it is due to a fever of miknowia nature. 
^^^lether or not the lab^Tinthine inflammation is the 
primary process to which the fever is due it is impossible 
to state. But the fact that even purulent lab\Tmthitis 
is often an afebrile disease, and when there is fever it is 
very moderate, inclines one to the belief that the disease 
under discussion is not the cause of the fever but the 
result of the process which produced the rise of tempera- 
tiue. 

Pathology. — In autopsies performed upon patients 
deaf from epidemic cerebrospinal meningitis, the most 
common condition present is an inflammation of the 
lab^Tinthine structures, if the examination is made soon 
after the onset of the inner-ear disease. Later there is 
formation of connective tissue and new bone. At times the 
lesion consists in inflammatory involvement of the eighth 
nerve with degeneration of the structm^s within the laby- 
rinth. Goerke^ in fifteen cases found the infection 
extended from the meninges to the lab^Tinth through 
the aqueductus cochlea thi'ee times, the aqueductus 
vestibuli once, and tlii^ough the internal auditory meatus 
eleven times. 

In diphtheria the symptoms are believed to be due to 
a toxic nem^itis of the eighth nerve. Alagna- has produced 

1 Deutsch. Otolog., 1906. 

2 Zeitschrift fiir Ohren., Bd. 59. 



392 NONSUPPURATIVE DISEASES OF INNER EAR 

degeneration of the spiral ganglion, in the modiolus of 
the cochlea, in animals by the injection of diphtheria 
toxin. Lewin^ found degenerative changes in the eighth 
nerve and its peripheral ganglia in a considerable propor- 
tion of patients dying of diphtheria. In measles and 
scarlatina the process is either a labyrinthitis or a degen- 
eration of the eighth nerve. When a labyrinthitis occurs 
in measles or scarlatina without middle-ear involvement, 
it is metastatic in nature. Considerable discussion has 
taken place as to the nature of the lesion in mumps. 
There seems, however, to be no very exact conception 
of its nature. It is probably similar to the processes 
which occur in the testicles or ovaries in this disease. A 
number of autopsies have been reported in which laby- 
rinthitis was secondary to non-epidemic purulent menin- 
gitis. The possibility of this occurring has been alluded 
to under Suppurative Diseases of the Labyrinth. 

Symptoms. — The sym])toms at the onset of the involve- 
ment of the labyrinth or eighth nerve, occurring as it 
does in a patient who is very sick with the disease of 
which this involvement is a complication, may be over- 
looked by the attendant who, i)erha])s, is not on the 
alert for their occurrence. Then again, the patient may 
be unconscious and the develoi)ment of the symptoms 
cannot be detected. In epidemic cerebrospinal menin- 
gitis the intensity of the disease seems to have nothing 
to do with the occurrence of deafness. \evy severe types 
may recover without aural involvement, while the abor- 
Hive types, in which the general symptoms are more 
mild, may develop aural complications. The symptoms 
when they may be observed are profound deafness, 
nystagmus, vertigo, nausea and vomiting, and if the 
patient attempts to walk, an unsteady gait. The attend- 
ant upon patients suffering with the infectious diseases 
should be on the alert for these symptoms, for until he 
is impressed w^ith their significance and especially with 

1 Zeitschrift fur Ohrenheilk., 1913, Ixvii. 



OTITIS INTERNA 393 

the importance of examining the labyrinth in all patients 
who die after manifesting them, knowledge of the patho- 
logical basis of this type of labyrinthine disease will make 
but slow progress. 

These patients come under the observation of the 
aurist suffering with profound deafness. Tinnitus is but 
seldom a symptom as the patients are mostly children who 
rarely complain of subjective noises. One may syringe 
the ear with cold water and produce no nystagmus or 
vertigo. If the disease is bilateral, one may rotate them 
without producing nystagmus. This is the rule, although 
at times there is some response to these tests, rarely being 
equal to normal. It would seem that for the acoustic 
reaction to be lost (deafness) while the static reactions 
were present, it would be necessary for the lesion to be 
in the lab^Tinth and affect the cochlea while the canal 
system escapes. This is the more rational explanation 
of deafness without loss of vestibular function. If one 
could examine the temporal bones of some of these patients 
who have had thorough examinations during life, the 
question might be settled. It is conceivable that a 
toxin might have a selective action on the cochlear com- 
ponent of the eighth nerve and produce deafness without 
at the same time destroying the vestibular function. 
Quinine and salicylic acid produce tinnitus and deafness 
without, in the great majority of instances at least, pro- 
ducing vertigo. That any coarse lesion as a tumor or 
exudate could select the cochlear component seems 
improbable. 

Diagnosis. — A patient with deafness, usually profound 
or absolute, which is due to a lesion of the perceptive 
mechanism, w^ho presents no changes of the drum mem- 
brane indicating that a suppurative process of the middle 
ear has been present, and who gives a history that the 
deafness occurred during one of the infectious diseases or 
a febrile attack, may be regarded as belonging to the 
type under discussion. 



394 NONSUPPURATIVE DISEASES OF INNER EAR 

Prognosis. — The prognosis is unfavorable. In rare 
instances some hearing is retained, but as a rule deafness 
is profound. Children under seven with binaural involve- 
ment usually become deaf-mutes. 

Treatment. — During the acute stage there are no means 
at hand to prevent or minimize the loss of function. 
After this stage is passed the iodides and pilocarpine 
should be used for several months in the hope of produc- 
ing some amelioration of the deafness. Educational 
exercises in lip-reading and the use of the voice should 
be begun as soon as possible after the attack. 

DEAF-MUTISM. 

Deaf -mutism is the impairment of hearing to such a 
degree that the child cannot acquire the art of speech, 
or, having acquired it is unable, on account of profound 
deafness, to retain it without being assisted by proper 
instruction. 

Mutism. — In order that the child may be able to learn 
to speak it must be able to hear the spoken words of 
others, that, by imitation, it may be able to utter them. 
Speech is usually acquired in the second and third years 
of life, so if there is some lesion or anomaly of the organ 
of hearing which results in profound deafness before this 
time, the child will not learn to speak. If by disease the 
hearing is lost during or after this period, the child loses 
the ability to use what speech he had acquired, unless he 
is promptly taken in hand by a competent teacher. After 
the seventh year if the hearing is lost, more or less speech 
usually remains. Even if the child becomes deaf before 
that time and after acquiring some speech it is frequently 
not entirely lost, the child still possessing a very limited 
vocabulary, to which the mother calls attention as evidence 
that he is not a mute. 

Etiology. — Deaf-mutism is usually divided into two 
forms, congenital and acquired. In the congenital form 
the condition resulting in deafness exists at birth, while 



DEAF-MUTISM 395 

in the acquired the impairment of hearing is caused by 
postnatal disease, occurring, as has been seen, at any 
time before the seventh year. Statistics seem to show 
that deaf-mutism is divided about equally between the 
two forms, although in an individual instance it may at 
times be' difficult to state whether the child was born 
deaf or acquired the deafness very early in life. A great 
deal of statistical work has been done to determine the 
cause of congenital deaf -mutism. There is no doubt 
but that heredity and consanguineous marriages are 
etiological factors. If congenital deaf-mutes marry, or 
cousins in a family in which deaf -mutism seems uncom- 
monly prevalent marry, there is great probability of some 
of the offspring being born deaf. Consanguineous mar- 
riages naturally increase any hereditary tendency that 
may exist, and it has been found that deaf-mutism is more 
frequent among people or communities who encourage 
marriage with relatives than among those who discom^age 
or prohibit it. For this reason isolated communities, as 
on islands or in mountainous districts, show an increase 
of this disease. Altitude seems also to be an etiological 
factor. In the Swiss Alps the proportion of deaf-mutes 
is larger than at the sea level. But in the former locality 
cretinism is very common and it is believed that many 
cases are reported as deaf-mutism, in which the dumbness 
is due to the mental inferiority of the patient and not to 
deafness at all. . 

The causes of acquired deaf-mutism are epidemic cere- 
brospinal meningitis, scarlet fever, measles, typhoid 
fever, diphtheria, erysipelas, chicken-pox, mumps and 
rheumatic fever. This by no means exhausts the list of 
causes to which deafness in infancy or childhood may be 
attributed. It may be stated that any condition which 
conduces to middle-ear suppurations may also be a 
cause, as a bilateral lab^Tinthine involvement in this 
disease often leaves the child permanently deaf. Thus 
adenoids become of etiological significance and many 
patients are brought to the clinics with profound deaf- 



396 NONSUPPURATIVE DISEASES OF INNER EAR 

ness in whom the nasopharynx is full of these growths. 
It seems impossible to consider adenoids as directly 
responsible for deafness, but indirectly as favoring infec- 
tion of the middle ear they may be a cause. Of the 
patients seen in the clinics of New York during the last 
ten years, the writer would place epidemic cerebrospinal 
meningitis first in causation, then follow closely scarlatina, 
diphtheria, and measles. Often it seems impossible to 
ascertain the cause, the mother stating that the child 
was all right until it had a fever, since which time she 
has noted the infirmity. Congenital syphilis is no doubt 
responsible for some cases. It is probable that its impor- 
tance in etiology has been underestimated. 

Pathology. — In by far the greater number of patients 
the lesion is in the sound-perceiving mechanism. While 
in some instances disease or malformations located in 
the conducting mechanism produce sufficient deafness to 
result in mutism, it is in a small minority of the patients 
that it does so. As autopsies are not frequently per- 
formed upon deaf-mutes in this country by observers 
who are alive to the importance of making a careful 
examination of the ear, knowledge of the pathological 
basis of deaf-mutism is derived largely from the work of 
those abroad, chiefly Mygind and Denker. Congenital 
atresia or absence of the external auditory canal is found 
during life responsible for some instances of deaf-mutism. 
In reports of autopsies are found instances of the fol- 
lowing conditions: absence of the ossicles or of the incus; 
ankylosis of the stapes; labyrinthine fenestrse absent or 
occluded; cochlea imperfectly formed, either consisting 
of one and a half turns, the apex being a cavity without 
structure, or the turns not formed at all; cochlea absent; 
absence of Corti's organ; entire labyrinth absent; semi- 
circular canals one or more absent or fused together and 
in abnormal position; auditory nerve degenerated and 
atrophied, internal auditory meatus contracted. These 
have all been found in the congenital form. Manasse 
has demonstrated the changes characteristic of otosclero- 



DEAF-MUTISM 397 

sis in very young children, and Alexander believes that 
this disease may occur in ntero and be the cause of con- 
genital deafness. Intra-uterine syphilis may result in 
the child being born deaf. Lab>Tinthitis following upon 
middle-ear disease, occurring immediately after birth, 
might produce deafness and it might be impossible to 
state at a subsequent time that the condition did not 
arise in ntero. The author operated upon a double sub- 
periosteal abscess in an infant ten days old. Otorrheas 
are not infrequent in the first two weeks in life and both 
ears are not seldom involved. So the possibility of the 
disease extending to the inner ear is not a remote one. 
In reading the autopsy reports in the acquired deaf-mut- 
ism, one is impressed with the great resemblance of the 
changes to those found in the latent stage of suppurative 
lab^Tinthitis. In very many instances the cochlea and 
semicircular canals are filled with osseous or fibrous 
tissue; occasionally the contents are of a caseous nature. 
As these lab^Tinthine changes are often found associated 
with various cicatricial distortions in the tympanum and 
drum head, it is probable that an otitis media purulenta 
leads to an infection of the labyrinth through the oval or 
round windows, with a consequent inflammation which, 
passing into the latent stage, resulted in the deposit of 
bone or fibrous tissue. This is perhaps the usual way, 
but there is no doubt but that labyrinthitis may occur 
by metastasis. There seems no good reason why scar- 
latina should not produce an inflammation of the laby- 
rinth as well as a nephritis, or why mumps should not do 
so as well as an ovaritis or orchitis. 

Symptoms. — ^The deafness must be profound to cause 
mutism in an otherwise normal individual. \Yith poor 
mental development a lesser degree of impairment of hear- 
ing will result in dumbness. In younger children it is 
difficult to determine what amount of hearing exists, and 
it is impossible to apply the tests by which the lesion is 
located in the sound-perceiving mechanism. Slapping 
the hands behind the child, taking care that a current of 



398 NONSUPPURATIVE DISEASES OF INNER EAR 

air is not produced that will be perceived by the tactile 
sense, is a favorite way. If the child's attention is held 
in some other direction and it turns around to investi- 
gate the source of the sound, it is safe to infer that it 
possesses some hearing. A tuning-fork held to the ear 
will at times cause a brightening of the expression, show- 
ing perception of sound. When one sense is lost the 
others become keener to compensate for it insofar as 
possible. These little patients are already beginning to 
be very acute with the sense of sight and touch. They 
will take notice of any sound which produces a coarse 
vibration. The tuning-fork placed upon the head prob- 
ably conveys to them only the vibration appreciated by 
the tactile sense. In older subjects one may ascertain 
that there is no bone conduction by the fact that they 
experience the same sensation when it is placed upon the 
olecranon or some other subcutaneous part of the skele- 
ton. In older children and adults, it will be possible to 
locate the cause of the deafness as being in the sound- 
perceiving or conducting mechanism. As a few of these 
patients possess some audition, it is very desirable to 
determine at the earliest moment possible how much is 
heard, and the pitch of the tones perceived. This is best 
done by the Bezold-Edelman continuous tone series, and 
if a tone island is found of such a pitch that the human 
voice may be attuned to it, great assistance in teaching 
the art of speech is afforded. Some patients with 
acquired deaf-mutism give a history of vertiginous symp- 
toms during the attack causing deafness. These are 
readily accounted for as the symptoms of the manifest 
stage of the labyrinthitis from which they suffered. 
Rarely this vertigo may persist for some time, but an 
unsteady gait is somewhat more common. Deaf-mutes 
are usually negative to the rotation and caloric tests, 
although occasionally one responds. It has been claimed 
that as deaf-mutes are not affected by currents of endo- 
lymph within their static labyrinths, as these cannot as 
a rule be produced on account of destruction of the 



DEAF-MUTFSM 399 

labyrinth, they are immune to seasickness. It is also 
stated that while they are able to swim on the surface as 
long as they can orient, or place themselves in space with 
their eyes, it is unsafe for them to dive beneath the water. 
However this may be, they are (usually) deprived of the 
static impulses normally derived from the labyrinth and 
are therefore less apt in maintaining their equilibrium 
under trying circumstances. 

Diagnosis. — ^The recognition of deaf -mutism is in the 
majority of patients comparatively easy. It must be 
determined that the patient is deaf and that on account 
of his deafness he does not speak. This is not difficult 
when the time of life arrives when the faculty of speech 
should be acquired. Before this time of life the question 
resolves itself into determining whether or not the patient 
is sufficiently deaf to be unable to acquire the art of 
speech. During the first six months of life this is impos- 
sible, although it has been demonstrated that even dur- 
ing this • period infants hear and take notice, although 
many do not react to sound. During the second six 
months the child should react to a loud sound, as of 
clapping the hands, ringing a bell, etc., but if they do 
not, one cannot pronounce them deaf. During the second 
year, when children are usually learning to talk, one 
cannot say that a child is deaf because he does not talk. 
Usually, however, the children readily react to sound, 
and if this is the case, enable one to assure the parents 
that in all probability the backwardness in speaking is 
not on account of the deafness and therefore not per- 
manent. It should also be determined whether or not 
the child is mentally defective. Cases of hysterical 
deaf-mutism occur occasionally and attract considerable 
attention in the lay press, but should not cause difficulty 
in diagnosis. 

Prognosis. — The prognosis as to the cure of the lesion 
causing the deafness is bad. This in most instances is 
permanent. Occasionally there is some improvement 
under treatment. Patients with a small amount of hear- 



400 NONSUPPURATIVE DISEASES OF INNER EAR 

ing and those who have at one time spoken make very 
encouraging pupils for special instruction in lip-reading 
and articulation, while in those totally deaf or who 
have never spoken the results obtained are not so good. 

Treatment. — The prevention of deaf-mutism, consists in 
improving the social and hygienic surroundings of the 
people at large, and the discouraging of intermarriage 
among relations, especially in families in which the con- 
dition has occurred. Congenital deaf-mutes should be 
discouraged from marrying for the same reason. Some- 
thing may be done to prevent the lesions which produce 
profound deafness in children by a rational treatment 
of the suppurative process to which they are secondary. 
The adenoids should be removed and the sui)purations 
treated along the lines already discussed. Of special 
value in preventing labyrinthine involvement is the 
establishment of early and sufficient drainage. After 
deafness has occurred a thorough examination is to be 
made and any measures which give promise of at all 
improving the hearing adopted. Even a slight diminu- 
tion of the deafness may result in taking the patient out 
of the mute class, although he may still be profoundly 
deaf. If atresia of the external auditory meatus exists 
and is bilateral, the question of attacking it surgically 
arises. Page's operation, alluded to under Microtia, 
doubtless saved his patient from becoming a deaf-mute. 

After a patient recovers from epidemic cerebrospinal 
meningitis, treatment, if begun early, is occasionally of 
some value. The administration of pilocarpine to the 
point of physiological tolerance, together with the iodides, 
sometimes, although rarely, ameliorates the deafness 
to a slight degree. It should be tried for the sake of this 
occasional patient. If some hearing remains, it must be 
used and encouraged. This may be done by the use 
of the various aids to audition, such as conversation tubes, 
trumpets, etc., and also by pitching the voice if possible 
in consonance with any tone islands which it has been 
ascertained that the patient possesses. By this means 



DEAF-MUTISM 401 

it may be possible not only to retain the hearing 
power, but also prevent the occurrence of mutism. The 
retention and improving of audition, when possible, is 
the best treatment for mutism. When impossible the 
patient must be taught to communicate either by signs 
or speech. The latter is unquestionably superior. It 
originated with a Spanish monk, Pedro de Ponce, but is 
nevertheless called the German method, and when attain- 
able is better than the former, sometimes called the 
French method. It is found that those patients who pos- 
sess some hearing, however little, and those who at one 
time were able to speak, acquire very much more pro- 
ficiency both in lip-reading and in the art of speech than 
those who do not have this advantage. ^Moreover, the 
length of time that the faculty of speech has' remained 
unused has a direct bearing also. The duty of the aurist 
is therefore clear and imperative, and that is to place any 
patient who has once been able to speak and has lost 
this faculty through deafness under the immediate care 
of a competent instructor. While waiting for the child 
to be "old enough'^ valuable time is sacrificed, the loss 
of which is irreparable. A child who has never spoken 
and is absolutely deaf should be put under instruction at 
least as young as three years. 

The subject of the method of instruction, as well as 
many other phases of this interesting subject, cannot be 
discussed within the limits of a book of this character. 



26 



CHAPTER XIII. 
GENERAL AURAL DISEASES. 

SYPHILIS OF THE EAR. 

External Ear. — Primary syphilitic affections of the 
external ear are rare, but several have been reported. 
They have been due to the patient being bitten by a 
syphilitic subject, or the virus being conveyed upon some 
intermediate substance as a towel, etc. Secondary affec- 
tions of the auricle occur as a part of a general macular, 
papular or pustular eruption. 

Condylomata. — Children may have condylomata on the 
posterior surface of the auricle, in the fold between this 
structure and the head, w^here the parts are often moist 
and macerated from intertrigo. Condylomata may 
develop in the meatus, especially if there is a middle-ear 
discharge. They occur as red or a grayish-red, ragged, 
warty excrescences, springing from the canal walls, usually 
at the entrance to the meatus, but they may invade the 
deeper part or even the osseous meatus as well. They 
are usually painless at first, but as thej^ become more 
developed they may cause pain, especially upon move- 
ment of the auricle. There may be deafness and sub- 
jective noises from obstruction of the lumen of the canal. 
They either heal by resolution or break down and form 
ulcers. Condylomata of the meatus disappear with anti- 
syphilitic treatment, but may leave more or less atresia 
of the canal. Local treatment consists in keeping them 
dry. 

Gumma. — Gumma of the auricle and canal is occa- 
sionally seen, and is usually associated with a similar 
process in the middle ear. It breaks down, forming an 
ulcer with a deep base and elevated margins. If one is 



SYPHILIS OF THE EAR 403 

alive to the possibility of the condition being specific, 
proper measures for diagnosis and treatment may be 
taken. 

Membrana Tympani. — A small gumma may be formed 
which may break down, producing a small ulcer on the 
surface of the tympanic membrane, although the process 
is more apt to produce a perforation or total destruction 
of the membrane. The author has had under his observa- 
tion a patient with a small granulating surface upon the 
tympanic membrane due to breaking down of a gumma. 
A thin discharge of a purulent nature was present. Infla- 
tion demonstrated the absence of a perforation. Was- 
sermann reaction strongly positive and history of s\^hilis 
(primary lesion occmring four years previously) was 
present. The condition proved quite stubborn, but 
finally yielded to antisji^hilitic treatment (mercurial 
injections) and applications of strong solutions of nitrate 
of silver. 

Middle Ear. — Suppurations in the middle ear may be 
caused by extension of a specific process in the naso- 
pharynx, through the Eustachian tube to the t^TQpanum. 
It may be difficult at times to determine whether one 
is dealing with a syphilitic otitis media or a simple pro- 
cess in a syphilitic subject. Rapid destruction of the 
membrane with a milder degree of pain may be expected 
if the process is specific. Occasionally such a process 
invades the mastoid, or the mastoid may be the seat 
of a gummatous infiltration not secondary to middle-ear 
syphilis. After operation if the nature of the process is 
not recognized the bone may become progressively 
involved and break down. The process may thus extend 
into the occipital bone, into the squama, and into the 
depth of the temporal bone, producing lab}Tinthitis and 
facial paralysis. The meninges may become thickened 
and agglutinated with the cerebral cortex. This condi- 
tion will, as a rule, rapidly clear up if the nature of the 
process is recognized and the patient put upon vigorous 
antis^^hilitic medication. 



404 GENERAL AURAL DISEASES 

Inner Ear. — Syphilis not infrequently involves the 
labyrinth and eighth nerve. 

Pathology. — Autopsies, which have been performed upon 
patients who had presented symptoms fairly attributable 
to syphilis of the inner ear, have shown the following 
conditions: thickening of the endosteum of the vesti- 
bule; stapediovestibular ankylosis associated with small- 
celled infiltration of the tissue between the membranous 
and bony labyrinths, of Corti's organ and of the mem- 
branous canals; degeneration of the spiral ganglion with 
small-celled infiltration and extravasation of blood between 
the fibers of the acoustic nerve; narrowing of the internal 
auditory meatus and deposit of new bone in the laby- 
rinthine spaces; round-celled infiltration in one or both 
acoustic nerves. Gummatous inflammation of the dura 
in the internal auditory meatus, or of the nerve sheath, 
may take place. Syphilitic meningeal processes may 
occur on the posterior surface of the petrous pyramid 
and lead to involvement of the eighth usually in conjunc- 
tion with other cranial nerves. The eighth nerve, on 
account of its consistence and its location in a canal 
where it may be subjected to pressure, is one of the most 
vulnerable of the cranial nerves. 

Course and Symptoms. — The eighth nerve or labyrinth 
is most frequently involved in the tertiary stage of syphilis, 
or on the border of the secondary and tertiary stages. 
That it may occur early in the disease and does so much 
more frequently than was formerly supposed, has been 
demonstrated through the impetus given to the study of 
syphilis by the discovery of the Spirocheta pallida, the 
complement-fixation reaction and the use of salvarsan. 
Otto Meyer^ found in the records of the Grazer ear clinic 
between 1896 and the inception of salvarsan medication, 
65 cases of disease of the inner ear, of which 20 per cent, 
began within the first year after infection. Instances 
have been reported in which the inner-ear involvement 
has occurred as early as two months after the initial 

1 Weiner klin. Woch., 1911, No. 11. 



SYPHILIS OF THE EAR 405 

lesion, so there is really no time in the secondary or ter- 
tiary stages that the specific patient is exempt. 

The symptoms are deafness, tinnitus and at times 
vertigo and nystagmus. The deafness usually comes on 
rather suddenly, that is, it develops and becomes pro- 
found within a few days, although there are occasionally 
instances of its slower progress. Tests show this deafness 
to be due to lesion in the perceptive mechanism, A. C. 
> B. C, B. C— and Weber to the good ear. One pecu- 
liarity which has been noticed about the tuning-fork 
tests is the marked shortening of the bone conduction. 
Instead of being one-half of air conduction with the 256 
D. V. fork, as occurs in many labyrinthine diseases, in 
s\T)hilis of the inner ear this ratio may be changed so 
that bone conduction is much less than half of air con- 
duction. In eliciting bone conduction in patients with 
very marked difference on the two sides, when the fork 
is applied to the deafer ear, it may be heard through the 
head on the side of the better ear and give rise to the 
impression that B. C.> A. C. (bone conduction is greater 
than air conduction) as the air conduction is very much 
shortened or even lost, that is, the patient does not hear 
the fork through the air but appears to through the bone, 
and this in an involvement of the perceptive mechanism, 
which of course is impossible. One will not make this 
error if he takes pains to ascertain on which side the 
patient hears the fork when applied to the mastoid. 
The bone conduction for the higher-pitched forks being 
naturally shorter than that for the 256 D. V. is lost first, 
that is, the 512 D. V. or 1024 D. V. forks will show loss 
of bone conduction in milder degrees of impairment of 
hearing than will the 256 D. V. or the lower forks. While 
much has been made of these bone-conduction tests with 
a series of forks, the writer is satisfied that as a rule one 
derives about as much knowledge of the kind and location 
of the lesion if he uses a good fork of 256 D. V. and accus- 
toms himself to rely on its findings. Tinnitus is a frequent 
symptom and may be very distressing. Some patients 



406 GENERAL AURAL DISEASES 

develop their tinnitus and deafness without vertigo, or 
this may be a very prominent symptom in the beginning 
of the attack. 

Vertigo is generally associated with nystagmus, espe- 
cially if one side only is affected or to a greater degree 
than the other. With the vertigo there may be vomiting 
and a tendency to fall, in fact all of the symptoms of 
disharmony described under Purulent and Serous Laby- 
rinthitis. These symptoms usually pass away, but the 
deafness remains. Unless ])r()mpt treatment is insti- 
tuted, it usually becomes profound. When these patients 
come under observation after a lapse of one or more 
months, the vestibular function is usually foiuid destroyed. 
They do not react to the caloric or to rotation tests if the 
disease is bilateral. If unilateral, the rotation test may 
show compensation or a negative reaction. In rare 
instances the hearing may be nearly or quite destroyed 
and the static labyrinth still remains active. 

Diagnosis. — Deafness occurring in a sy])liilitic subject 
(with or without vertigo and nystagmus) which tests 
show to be due to a lesion of the soiuul-])erceiving mech- 
anism, is presumably sy])hilitic in nature. If the bone 
conduction is less than half of air conduction, with the 
256 I). V. fork, it tends to strengthen the supposition. 
The possibility of such a process being other than luetic 
in nature should be disregarded and treatment instituted 
along antisyphilitic lines. In determining whether or 
not the patient is luetic, the history is carefully taken/ 
No matter how soon after the initial lesion the symptoms 
present, they are still to be regarded as indicating a pro- 
cess of specific nature. Due regard must be paid to the 
complement-fixation tests, although it is possible that the 
disease may be specific and that they should be negative. 
At times when the blood gives a negative reaction, if the 
cerebrospinal fluid is used a positive reaction may be 
obtained. So if there is doubt, the Wassermann reaction 
should be tried on this fluid obtained by lumbar puncture. 
It is often impossible to obtain a history of hereditary 



SYPHILIS OF THE EAR 407 

syphilis, but usually the subject of this form of lues 
presents its stigmata. There may be interstitial keratitis 
or evidence of its having been present, or the well-known 
Hutchinson's teeth. The characteristic of these incisors 
is that they are peg-shaped, that is, broader at the gum 
than at the cutting edge, whereas normal incisor teeth 
are broader at the cutting edge than at the gum. This 
condition of the incisors, with interstitial keratitis and 
deafness is known as Hutchinson's triad, and is very 
characteristic of hereditary s}T)hilis; although the aural 
involvement is less frequently seen than the ocular. 
To determine whether the lesion is in the lab^Tinth or 
involves the eighth nerve or its central connections, may 
be impossible. If the facial is also involved and no reason 
exists for believing that this is due to some process per- 
ipheral to the fundus of the internal auditory canal, it is 
safe to assume that the eighth together with the seventh 
is involved in this canal. If in addition to the facial the 
sixth, perhaps also the fifth, is implicated, the lesion may 
with a fair degree of certainty be located on the posterior 
surface of the petrous pyramid in the cerebellopontine 
angle. 

Prognosis. — The prognosis as to return of function is 
not good. If early treatment is adopted, the improve- 
ment at times may be truly remarkable, but the otologist 
usually sees these patients after irreparable injury has 
been done to the labjTinth or nerve, so that a moderate 
improvement is the most that may be expected. The 
patients who have inlierited syphilis are usually the most 
hopeless, but they may at times show some improvement. 

Treatment. — The patient should be put upon vigorous 
constitutional treatment at the earliest possible moment. 
This is especially necessary if he presents early in the 
involvement of the inner ear. He should be given mer- 
cury and perhaps also the iodides at once. On this there 
is now practical unanimity. ^Yhether or not he should 
also receive salvarsan has been a subject of much discus- 
sion. 



408 GENERAL AURAL DISEASES 

Salvarsan and Eighth Nerve Lesions. — ^After the use of 
salvarsan in the treatment of syphihs became more or 
less general, it was found that patients began to present 
themselves early in the disease and at varying times after 
the administration of salvarsan with involvement of the 
eighth and other cranial nerves. It was claimed on the 
one side that this neurorecurrence, as it was called, was a 
result of the syphilis itself and had nothing to do with 
the salvarsan, while the other side believed that it was 
due in a greater or less degree to the administration of 
this remedy. It was shown that syphilis of the inner 
ear was much more common in the early stages of the 
disease in the antesalvarsan period than was generally 
supposed. Moreover, many of these cases were reported 
in which the aural symptoms following a dose of salvar- 
san were improved or relieved by one or more adminis- 
trations of the remedy, or by mercurial treatment. Still 
many patients did not improve. The known effect of 605 
upon the optic and acoustic nerves when administered 
for sleeping sickness caused many to believe that the 
arsenic in ''606'' might be responsible for the neuro- 
recurrences. Without discussing the subject at length 
it may be stated that the opinion prevails, that while 
it is possible that the arsenic may cause involvement of 
the eighth, it does not commonly do so but that the 
condition is due to the growth of the spirochetae which 
have escaped the action of the salvarsan. Nichols'^ 
theory is probably true. He believes that while these 
organisms are in the main killed by the salvarsan, this 
remedy acts so thoroughly that no natural resistance is 
established as when mercurials are used, and a focus which 
may exist in the nervous system finds its development 
unopposed after the elimination of the salvarsan. The 
practice at present considered safe is as follows: if the 
inner-ear involvement occurs in the early stages, salvar- 
san followed by full doses of mercury should be given; if 

1 Journal Amer. Med. Assn., March 2, 1912, 



TUBERCULOSIS OF THE EAR 409 

in the later stages, it is well to give mercury for a short 
time before ''606" is administered, and continue the 
mercurial treatment for some time afterward. For the 
neurorecurrences which follow the use of salvarsan, 
mercurial treatment is the best prevention and, associated 
with salvarsan, offers the best prospect of cure once the 
condition is present. 

TUBERCULOSIS OF THE EAR. 

External Ear. — Tuberculosis of the auricle may exist 
as one of the forms of lupus. The consideration of these 
conditions is within the province of the dermatologist, as 
they rarely present any phase of interest to the otologist. 

Middle Ear. — An otitis media or mastoiditis may occur 
in a tubercular subject and be due to infection with other 
pyogenic organisms, or the process may be caused by 
the tubercle bacilli. These latter organisms may be 
found in the aural pus or careful search may fail to show 
them, even when the clinical picture seems characteristic. 

Causation. — The disease may be primary, which is 
considered of uncommon occurrence, or secondary to 
tuberculosis in the lungs, lymph nodes, nasopharynx or 
osseous system. In the act of coughing, the tubercular 
pus is often thrown with force into the nasopharynx and 
it would seem to be easy for it to reach the middle ear 
through the Eustachian tube. This, no doubt, is fre- 
quently the case and is the usual mode of infection in 
those tubercular middle-ear processes which occiu' in a 
comparatively late stage of pulmonary disease, when 
expectoration of material swarming with bacilli is the 
rule. Adenoid vegetations or tonsils which, as is well 
known, are frequently the seat of tubercular foci, seem 
favorably located to produce middle-ear infection either 
through the lumen of the Eustachian tube or through 
the submucous lymphatics situated in this structure. In 
general miliary tuberculosis the infection takes place 
through the lymphatics or blood stream. When diseased 



410 GENERAL AURAL DISEASES 

lymph nodes, are present in the neck, the question whether 
they are secondary to the aural process or the converse 
may arise. It has been shown that many of the acute 
suppurations of the middle ear in children are of a tuber- 
cular nature. 

Pathology. — The examination of the mucous membrane 
of the middle ear shows round-celled infiltration, giant 
cells, groups of tubercle bacilli with foci of destruction 
of the membrane. Tubercular nodes are found in the 
granulations. The process has a marked tendency to 
affect the bone, producing necrosis, caries or softening. 
The ossicles are often destroyed and the labyrinth or 
Fallopian canal invaded. The mastoid, especially if of 
pneumatic type, is invaded and the inner table broken 
down, producing extradural collections of pus. 

Symptoms. — As to the symptoms produced by tul)er- 
cular invasion of the middle ear and mastoid, two types 
are fouud. In the first the clinical history very much 
resembles the ordinary acute suppurative otitis media, 
and the second is characterized by the absence of reac- 
tionary symptoms. In the former type the onset is acute 
and the nature of the process may not be suspected until 
the occurrence of great destruction of the membrana 
tympani, multiple perforations, or the enlargement of 
the neighboring lymph nodes calls attention to its probable 
nature. The rapid formation of granulations in acute 
otitis media often occurs in tubercular processes. Facial 
paralysis and labyrinthine complications are more fre- 
quent also. Next to cholesteatoma, tuberculosis is the 
most common cause of fistula of the labyrinth. It is 
also not rarely responsible for diffuse suppurative laby- 
rinthitis with sequestration of a greater or less part of 
the labyrinthine capsule. In the chronic type the dis- 
charge appears without pain. There may be more or 
less discomfort and feeling of stuffiness in the ears, but 
usually the patients do not come under observation until 
the ear is discharging and w^hen questioned give no 
history of pain or discomfort, but come for the discharge 



TUBERCULOSIS OF THE EAR 411 

and deafness which is present. From the fact that this 
type of tuberculosis of the ear is more apt to be recog- 
nized on account of this characteristic absence of pain, 
it has been erroneously stated that tubercular otitis media 
occurs without pain. An accumulation of pus within the 
ear sufficient to produce rupture of the di^um membrane 
will produce pain. In the chronic type the membrane 
is involved and breaks do^^^i before the tension within 
the tympanum becomes sufficient to cause pain. 

Signs. — If a patient with the painless type comes under 
observation early, the appearance of the drum membrane 
is quite characteristic. It is of a dull red or pink color, 
the luster is diminished and the membrane seems thick- 
ened. At one or more points are areas which appear of 
a yellowish color. These are the seat of tubercular 
nodules in the process of breaking do^^i. In some 
instances this goes forward slowly and these areas are 
not converted into perforations for a month or more, in 
others the time required is less. If the ear is inflated, 
moisture will usually be found present. During this 
time the patient has deafness and perhaps tinnitus but 
no pain. 

When perforations are present they may appear 
not unlike the ordinary ones or their margins may be 
thickened and apparently everted, the thickened edges 
having a grayish or yellowish color. If the perforation 
is a large one, the internal tympanic wall may be seen to 
be covered with granulations, among which bare or loose 
pieces of bone may at times be detected with a probe. 
At times caseous material may be found in the middle 
ear and the mastoid at operation may be found to be filled 
with the same cheesy material. 

Diagnosis. — The diagnosis in patients in whom the 
onset is painless may not be difficult. This feature alone 
calls one's attention to the probable nature of the process. 
If upon examining the drum membrane multiple per- 
forations are found or a single one with characteristic 
margins, one is justified in assuming that the process is 



412 GENERAL AURAL DISEASES 

a tubercular one. If the patient also has tuberculosis 
of the other parts, it substantiates the diagnosis. If the 
patient is seen before the tympanic membrane ruptures 
in this type of case, its appearance is sufficiently charac- 
teristic to justify a diagnosis, especially if pulmonary 
tuberculosis is present. 

In the acute types which develop with reactionary 
symptoms the nature of the process is often not made out 
or even suspected at first. The author has been impressed 
with the considerable number of i)atients who have 
apparently developed pulmonary tuberculosis after the 
mastoid operation. The middle-ear process and compli- 
cating mastoiditis have given no clinical manifestations 
which have attracted attention to the probability that 
the process was tubercular, and yet, during the healing 
of the mastoid wound, the i)atient is found to have pul- 
monary tuberculosis, which gave no symptoms directing 
attention to its presence prior to the otitis media and 
mastoiditis for which operation became necessary. The 
possibility naturally suggests itself that the pulmonary 
disease in such instances may have been secondary to 
the process in the middle ear and mastoid. 

An aid to diagnosis is the von Pirquet reaction. This, if 
positive in a child under two years of age, is highly sugges- 
tive that the process is tubercular, especially if no other 
process of this nature is present. The most certain method 
of making the diagnosis in doubtful cases is to sul)mit 
tissue excised from the middle ear to microscopic exami- 
nation. If tubercular bacilli are found in the aural pus 
in fair quantity, one would be justified in assuming that 
the process w^as tubercular. It has, however, been found 
that they may not show in smears or grow in cultures of 
aural pus from processes evidently tubercular. Inoculat- 
ing a guinea-pig has sometimes demonstrated their 
presence in such instances. Sometimes the pig dies from 
the effect of the pyogenic organisms which exist in the 
pus injected, and the experiment is without value. If it 
proves successful, the result is not known until valuable 



TUBERCULOSIS OF THE EAR 413 

time has been lost. A method of obtaining bacilH from 
smears and cultures is described by Cocks and DAAyer.^ 
It is as follows: 

"The discharge was obtained in as large a bulk as 
possible in a small quantity of normal salt solution, the 
latter being used in an amount just sufficient to wash 
out the pus. The water used in making up the salt solu- 
tion was freshly distilled each day in order to be sure 
that none of the acid-fast organisms present in tap water 
or in old distilled water could vitiate our results. This 
discharge was then treated with an equal amount of 15 
per cent, antiformin, and the whole was allowed to stand 
for a varying period, depending upon the consistency 
of the mixture, etc. It was then centrifugalized, and the 
precipitate was washed in order to remove the excess of 
alkali. Smears were then made from the precipitate 
and stained by the Ziehl-Xeelson and Pappenlieimer 
method. In this way we were able to demonstrate the 
organism with reasonable certainty. By this method, 
no matter how much care is exercised, there is always an 
element of uncertainty in morphological diagnosis alone, 
as in many of the old chronic suppurating ears the acid- 
fast epithelioid flakes are apt to be mistaken for tubercle 
bacilH. These flakes are present in a large proportion of 
chronic cases. 

"In the series reported below, an effort was made to 
isolate the organisms from the discharge and cultivate 
them directly upon special media, so that there could be 
no question as to the diagnosis. Thus, animal inoculation 
was eliminated and much time was saved. This was made 
possible by the use of Petroft'^s media, a full account of 
which appears in the Journal of Experimental Medicine, 
January, 1915. During the summer of 1914, Petroff, 
working in the bacteriological laboratory of the College 
of Physicians and Surgeons, Columbia University, devised 

1 Laryngoscope, St. Louis, March, 1915. 



414 GENERAL AURAL DISEASES 

a specific medium, which we have used successfully for 
cultivating the tubercle bacillus. Thus far we have tried 
this method on the discharge from thirty chronic sup- 
purating ears, and have isolated tubercle bacilli in three 
cases. The three positive cases were found in making 
the routine examinations of children who presented them- 
selves at the Manhattan Eye, Ear and Throat Hospital, 
suffering from chronic purulent otitis media. 

^'The method we employ is somewhat different from 
Petroff's. It is really a combination of Petroff's method 
of isolating from sputum and his method for feces. This 
modification was rendered necessary by the large number 
of spore-forming organisms often present in chronic 
otitis. Our technic is as follows: 

^' After obtaining the aural discharge in wide-mouth 
bottles, it was immediately saturated with sodium chlorid 
and allowed to stand for from half an hour to an hour. 
At the end of this time, the bacteria are foiuid floating on 
the surface. This floating film is then collected with a 
deflagration spoon in a wide-mouth bottle, and an equal 
volume of normal sodium hydroxid added. The mixture 
is*shaken well, and left for digestion in the incubator at 
37° C, for one or two hours, or longer, care being taken to 
shake it every half-hoiu\ The mixture is then neutralized 
to sterile litmus paper with normal hydrochk)ric acid, 
and the sediment is inoculated into several test-tubes. 
Growth usually occurs in from fifteen to thirty days.'' 

Prognosis. — ^The prognosis in tuberculosis of the middle 
ear is as a rule unfavorable. When it occurs in advanced 
pulmonary tuberculosis it may not materially contribute 
to the fatal outcome. In some instances, however, it 
leads to a fatal issue by producing labyrinthitis and menin- 
gitis. The possibility of the process being primary and 
acting as a focus of infection should also be borne in mind. 
If the patient's general health improves, the local ear 
process sometimes gets well. iVfter the mastoid operation 
the wound may heal, but it frequently fails to do so. 



TUBERCULOSIS OF THE EAR . 415 

Treatment. — In primary tuberculosis of the mastoid and 
middle ear, free opening of the bone and removal, so far 
as possible, of all diseased tissue is indicated. In children 
with complicating enlarged lymph nodes, a like procedure 
should be undertaken. In the chronic type occurring in 
pulmonary tuberculosis the condition of the lungs largely 
determines whether or not operation is advisable. The 
process in the temporal bone may be of such a nature as 
to menace life, and must then be dealt with surgically. 
The bone destruction may progress without producing 
marked symptoms and the insidious nature of the process 
must be borne in mind. If the pulmonary condition is 
quiescent, the general nutrition good, and the local aural 
disease seems to be hindering convalescence, an opera- 
tion is justifiable. If, on the other hand, the disease in 
the lungs is getting worse and the disease in the temporal 
bone seems merely an incident, operation will only hasten 
the end. An item is the effect of the anesthetic on the 
lungs. If it becomes necessary to perform an operation 
on a patient with pulmonary involvement, ether should 
not be administered. The safest anesthesia is by the 
^'gas-oxygen'' method, which seems to have less unfavor- 
able effect on the lungs. The general health of these 
patients with tubercular ear processes demands special 
attention. Their resistance and nutrition should be 
increased by all means possible. 

Inner Ear. — Tuberculosis of the inner ear usually 
assumes one of the forms of labyrinthitis which are 
secondary to middle-ear suppuration, either sequestra- 
tion of a part of the labyrinth leading to a circumscribed 
inflammation, or the death of the bone, resulting in 
diffuse purulent labyrinthitis. These sequestrations of 
the labyrinthine capsule may be of sufficient size to 
embrace nearly the entire lab}Tinth, exposing the carotid 
artery, and leading in extreme instances to almost total 
destruction of the petrous pyramid. The facial nerve in 
such a process would naturally be destroyed, and it may 
be involved in the lesser ones also. The treatment is 



416 GENERAL AURAL DISEASES 

to remove the sequestrum, drain the labyrinth or adopt 
other operative procedures, according to the indications 
which are discussed under Labyrinthine Diseases Com- 
pUcating Purulent Otitis Media. 



TRAUMATIC LESIONS OF THE EAR. 

External Ear. — Traumatic lesions of the auricle some- 
times occur. The contusions have been alluded to as 
producing hematoma. Incised and lacerated wounds are 
treated upon general surgical principles. Care must, 
however, be taken to prevent infection on account of the 
danger of perichondritis. It may be necessary before 
closing a lacerated wound to dissect out some of the 
cartilage to prevent it being exposed during the healing 
process. Its removal minimizes the danger of perichon- 
dritis. 

Middle Ear. — A fracture of the base of the skull may 
invade the tympanic cavity without at the same time 
involving the labyrinth. If the membrana tympani is 
ruptured, blood appears in the meatus. The mere presence 
of blood does not indicate that the tympanum is involved 
and the membrane ruptured, as fracture of the external 
auditory canal or simple laceration of its membranous 
portion may cause hemorrhage from the ear. If the 
lesion involves the tympanum and the membrana tym- 
pani does not ruptiu-e, the blood accumulates internal 
to this membrane, producing a bluish appearance. The 
question may arise whether or not the membrane should 
be incised to allow the escape of the blood. One usually 
hesitates before doing this on account of the danger of 
introducing infection, but if pain or signs of inflammation 
are present it becomes one's plain duty to do so, and to 
treat the patient as for a purulent otitis media. If such 
a patient should develop symptoms of a mastoiditis, one 
would operate early, as the possibility of infection entering 
the cranial cavity through the fissure produced by the 



TRAUMATIC LESIONS OF THE EAR 417 

injury would cause one to assume no added risk by delay- 
ing operation. 

Inner Ear. — The fissure may extend through the 
lab\Tinth involving the terminal apparatus of the eighth 
nerve, or tln-ough the internal auditory meatus affecting 
the trunk of this nerve. Nor does it seem necessary that 
the bone should be fractm*ed to produce a serious lesion 
of the nerve or lab^Tinth, as at times the concussion is 
sufficient, the mere jarring seems to so change the delicate 
structures that loss of function results. 

Symptoms. — Lesions of the inner ear as a result of frac- 
ture of the base usually give few symptoms, as the patient 
is unconscious from the injury. If, however, this is not 
the case, there will be deafness, tinnitus, vertigo, and 
nystagmus, of which the deafness, perhaps the tinnitus 
also, is usually permanent. In concussion of the laby- 
rinth vertigo and nystagmus may be present during the 
early stages in addition to the deafness and tinnitus. 

Diagnosis. — ^The otologist usually sees these patients 
at some time after the injury when the vestibular symp- 
toms have subsided and the deafness, and perhaps also 
the tinnitus, remains. It is usually not difficult to satisfy 
oneself that the labyrinth or eighth nerve has been 
injm^ed, by the history of injiu-y and deafness due to 
lesion of the sound-perceiving mechanism, probably also 
loss of caloric reaction and change in the rotation reaction. 

Medicolegal. — In medicolegal cases it is necessary to 
determine that the patient's hearing was good before the 
injury. A claim for damages may be made and loss or 
impairment of hearing attributed to an injury which the 
claimant alleges he has received. If it can be proved that 
his hearing was good before the injury, while after it he 
suffered from deafness which can be demonstrated to be 
due to a lesion of the perceptive mechanism, it is a reason- 
able inference that some lesion of the labyrinth or nerve 
was caused by the injury. 

Prognosis. — ^The prognosis in those patients who show 
total loss of function is unfavorable. If the impairment 
27 



418 GENERAL AURAL DISEASES 

of hearing is less, it becomes more favorable. However, 
it is always more or less uncertain. 

Treatment. — During the first stage after injury and in 
the presence of symptoms referable to lesion of the static 
mechanism, rest in bed with the head elevated and cold 
applications to the head should be ordered. A certain 
number of fractures of the base cause death by meningeal 
infection introduced through a perforation in the drum 
membrane. Hence, the ear should be syringed with a 
bichloride solution and boracic acid insufflated. For the 
after-treatment the iodides may be given. Strychnine 
has proven of value in the patients with "concussion of 
the labyrinth." Pilocarpine should be given a trial for 
a month or so. 

Mauthner^ has written at some length on traumatic 
affections of the inner ear. 

1 Arch, fur Olircnlicilk., Ixxxvii, 146. 



CHAPTER XIV. 
TINNITUS AURIUM. 

The subjective sensation of sound is a symptom which 
has been constantly alluded to in these pages as tinnitvis. 
It is an aural symptom of very common occurrence, and 
is usually associated with deafness. The term subjective 
noises is usually applied to the sensations of sound which 
have no physical basis outside the patient. It is necessary 
that the patient recognize this fact, otherwise his belief 
that the noise is produced outside would constitute an 
hallucination. If the sound can be perceived by the 
examiner, it is called an entotic noise. This term is evi- 
dently an incorrect one, as in many instances the sound 
does not arise in the patient's ear, but is due to some 
abnormality in the intracranial circulation. Frequently 
the patient, while recognizing the subjective nature of 
the noise, cannot resist the belief that the sound ought to 
be heard by others also. One is not infrequently asked 
if he cannot detect the noise through the auscultation 
tube. If this is possible, which is rarely the case, it is 
called an entotic noise. 

Variety. — The varieties of sounds described by patients 
is endless. "Hissing as of escaping steam,'' ''humming," 
''ringing," "roaring," "clanging," "buzzing as of a bee," 
or some other insect, are some of the terms applied. 
The sound may remain more or less continually in one 
pitch, or may vary from day to day. Sometimes a musical 
tune will be heard, or a short strain repeated over and 
over again. The noise may be continuous or stop for 
intervals. Not infrequently it is of a pulsating character, 
occurring with greater intensity at the time of the cardiac 
systole. 



420 TINNITUS AURIUM 

Causes. — Occurring as they do in diseases of the auditory 
nerves, of the labyrinth, and of the conductive mechanism, 
it is evident that more than one cause may operate to 
produce these perversions of hearing. An irritation of 
the auditory nerve may produce the subjective sensation 
of noises. This may be due to disease of this structure, 
or from the effect of various substances which seem to 
have a selective action upon the nerve such as quinine, 
salicylic acid, and the toxins generated in disorders of 
the digestive organs. It is stated by some authors that 
they are always caused by irritation of the auditory nerve 
or its terminal filaments in the labyrinth. While this 
may be true in the majority of instances, it cannot be 
conceded in every case. If one occludes the external 
auditory meatus with the finger, there is immediately 
produced a rumbling sound. This is not produced by 
irritation of the auditory nerve or its terminal filaments. 
The explanation for this phenomenon doubtless accounts 
for the production of tinnitus in many instances in which 
it is present as a symptom of disease in the sound-con- 
ducting mechanism. The noise produced by the circula- 
tion of the blood in the lab;yTinth and the bloodvessels 
adjacent to it is below the threshold stimulus for the 
perceptive mechanism, and therefore is not heard by the 
normal ear. It is known that with disease of the conduct- 
ing mechanism, vibrations of the labyrinthine fluid pro- 
duce more eftect upon the acoustic apparatus. This 
accounts for the increased bone conduction which is 
present in these diseases. The labyrinthine fluid is with 
more difficulty set in vibration by aerial conduction on 
account of the disease, but if caused to vibrate by conduc- 
tion through the bone, the fork is heard louder and longer 
on account of the disease. It is evident that the sound 
produced by blood circulating in the labyrinth and vessels 
adjacent to it produces an effect which in the normal 
state is inaudible, but with the increased perception for 
a given vibration of labyrinthine fluid, which has been 
shown to occur in diseases of the conducting mechanism, 



TREATMENT 421 

it rises into consciousness and is perceived as a noise. 
This accounts for the sound perceived when the finger is 
inserted into the ear, and also doubtless for many subjec- 
tive noises. Strictly speaking, sounds produced in this 
manner have a physical basis, while those produced by 
pathological irritation of the acoustic nerve arise solely 
from a stimulation of a non-sonorous character which 
is interpreted as sound. Increased labyrinthine pressure 
may also cause tinnitus. This doubtless acts by producing 
some disturbance of the organ of Corti which is interpreted 
as sound. 

Prognosis. — The prognosis of subjective noises depends 
largely upon the disease of which their occurrence is a 
symptom. In the suppurative middle-ear diseases they 
are more apt to disappear than in the hyperplastic form 
of chronic catarrhal otitis media. In tubal catarrh, 
tubotympanic congestion and the exudative type of 
O. M. C. C, the prognosis is not so bad. In otosclerosis 
they frequently persist even at times when deafness is 
profound. In nervous subjects tinnitus has led to suicide. 

Treatment. — The treatment of noises has been detailed 
under the various diseases in which this symptom occurs. 
It is desirable to keep the patient's mind, as much as 
possible, from concentrating upon the tinnitus. Con- 
stipation is able to keep up the tinnitus or intensify it. 
Increased arterial tension is at times responsible for 
it, so the blood-pressure should be taken and if high, 
measures adopted to reduce it. In severe cases when 
death becomes preferable to enduring the noise longer, 
the possibility of relief by surgical measures naturally 
suggests itself. While these are more or less disappoint- 
ing, they may be tried after acquainting the patient 
with the risks and probable result. Dr. Dench divided 
the auditory nerve at the internal auditory meatus in a 
patient with tinnitus which was so distressing that he 
preferred total deafness, and was willing to run the 
danger of the operation rather than bear the noise longer. 
The operation, successfully performed, resulted in relief. 



422 TINNITUS AURIUM 

ENTOTIC NOISES. 

Unlike the perversions of hearing, the examiner is able 
to hear the entotic noise. They are of two types: a click- 
ing, snapping sound, and a blowing murmur, usually inten- 
sified with the cardiac pulsations. The clicking sounds 
may be due to some movement of the Eustachian tube 
or to spasmodic contraction of the tensor tympani. At 
times a patient is able to produce them at will, and thus 
becomes quite a curiosity. In other instances they are 
beyond the control of the will. The writer treated a 
patient throughout a year, during which time the snapping 
noise occurred with more or less regularity every one to 
five minutes. According to the statement of the patient, 
she was never free from the noise. By carefully observing 
the throat, it was possible to see a movement of the palate 
at the instant the snap occurred. It was therefore 
probably due to contraction of the muscles' in relation 
with the Eustachian tube. A patient may have the 
noise only at irregular intervals. It is usually necessary 
to use the auscultation tube to hear these noises. Treat- 
ment seems to be of very little avail. Usually, however, 
the noise disappears of its own accord in time. 

Vascular Murmurs. — The vascular murmurs may be 
due to enlarged arteries in the tympanum, to aneurysms 
in the intracranial arteries or of those in the neck. The 
following case, personally communicated by Dr. Don 
Campbell, of Detroit, is of interest in this connection: 
Male, aged twenty-two years, student, complained of 
inability to use his eyes. Had optic neuritis and bitem- 
poral hemianopsia. Loud murmur at the ear which could 
be heard by the patient and also by the examiner. There 
was increasing deafness. It was believed that an aneurysm 
was present. The common carotid was tied with tem- 
porary improvement. Patient died three years later and 
autops}^ revealed large cyst of the pituitary body pressing 
upon the carotid. It may be stated that the patient was 
under observation before the diseases of the pituitary body 



EN TOT I C NOISES 423 

were as well understood as they are today. Another 
patient recently seen, under the care of Dr. Alexander 
at the New York Eye and Ear Infirmary, presented a 
bruit which was audible through the auscultation tube, 
but much more plainly when the examiner's ear was 
placed in contact with the temporal region anterior to the 
auricle. X-ray examination shows enlargement of the 
sella turcica. 

The prognosis of the vascular sounds varies with the 
condition causing them, and as much may be said of the 
treatment which is usually surgical, the nature of which 
must be determined bv indications outside of the ear. 



INDEX. 



Abducexs paralvsis, anatomv of, 
374 
diagnosis of, 377 
pathology- of, 376 
prognosis of, 377 
SATnptoms of, 377 
treatment of, 377 
Abrasion of meatus as cause of 

furimcle, 116 
Abscess, adjacent to auricle in 
furujicle, 117 
of brain, 356 

formation of capsule in, 357 
deep temporal, 202 
extradural, 201, 22S, 343, 344, 

345 
in internal auditor^^ meatus, 

327 
perLsinus, 201 
retropharyngeal, in abducens 

paralysis. 377, 378 
subperiosteal, 207, 211 
A. C. See Air conduction. 
Accidents of catheterization, <1. 
72 
of ossiculectomy, 273 
Acumeter, PoHtzer's, 73 
Acute inflammation of middle 
ear, 164 
anatomy of, 164 
definition of, 164 
purulent otitis media, 170 
Additus ad antrum, 24, 195 
Adenoids as a cause of aural 
disease, 135, 143, 165, 171, 
206, 233, 249, 263, 409 
removal of, in O. M. P. A., 181 



Adhesive treatment for removal 

of foreign bodies, 110 
AcUadokokinesLs, 363 
After-treatment of mastoid 
wounds, 232 
of radical cavities, 289, 292 
Air, absorption of, from t^Tn- 
panum in tubal catarrh. 134 
pressure, tympanic, increased 
after inflation in tubal 
catarrh, 136 
minus, as cause of tubo- 

tympanites, 137 
in tubal catarrh. 134 
Alagna, 391 
\lcohol in the treatment of 

otomvcosis, 116 
Alexander, Dr. Dade, 34S, 3S4, 

397, 423 
.Alport. 215 

Aluminum acetate in treatment 
of am-al disease, 93, 102, 103, 
113, 119 
.\mpullae, crista? of, 33 
Anastamosis of facial with h^iDO- 
glossal, 372, 373 
with spiaal accessory, 373 
Anemia of labyriath, 387 
causation of, 387 
diagnosis of, 388 
prognosis of, 388 
svmptoms of, 387 
treatment of, 388 
Anesthesia in aural operations, 

110, 183, 219, 270 
Angular forceps, 55 
Anod\Ties in acut« otitis media, 
170, 179 
in mastoiditis, 214 



426 



INDEX 



Antrum, depth of, 277 

guides to, 196 

landmarks for, 276, 277 

opening in radical mastoid 
operation, 276-279 
Apathy, mental, in brain abscess, 

359 ■ 
Aphasia in cerebral abscess, 361 
Apoplexy of labyrinth, 383 
Apparatus for catheterization, 

selection of, 64 
Aqueduct of Fallopius, 23 
Aqueductus cochlea?, 40, 45 

vestibuh, 38 
Argyrol in tubal catarrh, 136 
Arnold's nerve, 106 
Arteriosclerosis as a cause of 

anemia of labyrinth, 387 
Artery, carotid, 242, 243 

internal auditory, 42 
Aspergillus, mycelial web of, 115 

sporangea of, 114 

varieties of, in otomycosis, 114 
Ataxia in cerebellar abscess, 361 
Atresia of external auditory me- 
atus, 124 
Atrium, tympanic, 164, 171 
Audition, functional tests of, 72 

physiology of, 44 

range of, 76 

theories of, 45 
Auditory nerve, 42 

irritation of, as cause of tin- 
nitus, 420 
Aural fungi, 114, 115 

speculum, 53 

tuberculosis, 409 
Auricle, anatomy of, 17 

blood supply of, 18 

burns of, 93 

condylomata of, 402 

cutaneous diseases of, 89 

deformity of, after hematoma, 
102 
after perichondritis, 104 

diseases of, 84 

eczema of, 91 

frost-bite of, 93 

function of, 17 

gumma of, 402 

hematoma of, 100 

ligaments of, 18 



Auricle, malformations of, 84 
perichondritis of, 102 
prominent, operations for, 88 
tenderness upon moving in 
diffuse otitis externa, 
112, 113 
in furuncle, 117, 118 
traction upon, in making aural 
examinations, 55 
Auscultation during politzeriza- 
tion, 63 
tube, selection of, 63 
Auto-inflation in perforations of 

membrana tympani, 60 
! Valsalva's method, 62 
Autophony in exudative type of, 
O. M. C. C, 144 
in tubotympanites, 139 

B 

Babinski reflex, 349 
Bacteremia in sinus thrombosis, 

238, 239 
Bacteria in ])rain abscess, 357 

in tubal catarrh, 134 
Bacteriological diagnosis of aural 

tuberculosis, 412, 414 
Bacteriology of discharge in 
extradural abscess, 344 
of O. M. P. A., 172 
of spinal fluid in meningitis, 
349, 350 
Baer's hyperemia treatment, 214 
Ballance meatal flap, 286 
Barany's fixator, 319 
noise apparatus, 75 
Basilar membrane, 39, 45 
Bathing as cause of O. M. C. A., 
165 
tubal catarrh, 133 
B. C. See Bone conduction. 
Bechterew, nucleus of, 43 
Berens, T. Passmore, 348 
Bezold's triad, 160 

type of mastoiditis, 192, 203, 
208 
Bezold-Edelmann continuous- 
tone series, 77, 398 
Bichloride of mercury in treat- 
ment of O. M. P. C, 264 
of otomycosis, 116 



INDEX 



427 



Bifid lobule, 89 
Bing's experiment, 83 
Blake's attic syringe, 265 
Blebs on drum membrane in acute 
myringitis, 127 
in otitis externa hemorrhagica, 
97 
Bleeding sinus, cases of, 247 
pathology of, 247 
treatment of, 248 
Blood-clot treatment of mastoid 
wounds, 234 
culture in sinus thrombosis, 

238, 239 
pressure, high, as cause of tin- 
nitus, 421 
Bone conduction, 79 

in advancing age, 82 
causes of increased, 79, 80 
in chronic catarrhal otitis 

media, 144, 155 
in disease of the perceptive 

mechanism, 381 
precautions in taking, 81 
relation of, to air conduction, 

80 
in syphilis of the perceptive 

mechanism, 405, 406 
in tubo tympanites, 139 
necrosis in aural tuberculosis, 
410 
Boracic acid in treatment of 
aural disease, 112, 128, 129, 
264, 265 
Boucherons's aural specula, 53 
Bougies, Eustachian, author^s, 
154 
method of introduction, 154 
Brain abscess, 356 
causation of, 356 
as a cause of purulent lepto- 
meningitis, 346 
diagnosis of, 360 
formation of capsule in, 357 
localizing symptoms of cere- 
bellar abscess, 361 , 362 
cerebral abscess, 361 
operation, cerebellar abscess, 
antero-internal ap- 
proach, 366 
posterior approach, 
367 



Brain abscess, operation, cere- 
bellar abscess, after- 
treatment of, 368 
cerebral abscess, external 
approach, 364 
internal approach, 
363 
pathology of, 357 
prognosis of, 363 
spontaneous cure of, 358 
symptoms of, 358 
treatment of, 363 
hernia, treatment of, 368 
Bridge, forming and taking down 
the, in radical operation, 379- 
282 
Brlinings, 320 
Burns of auricle, 93 



Caloric test for static irrita- 
bility, 310 
CampbeU, Dr. Don, 422 
Canal, Fallopian, 23 

of Hagier, 32 
Canalis reuniens Hensenii, 38, 40 
Canals, semicircular, ampullae of, 
33 
anatomy of, 33 
position of, 34 
relations of, 34-36 
Cantharidal collodion in treat- 
ment of eczema, 92 
Cap, tape, for prominent ears, 87 
Capsule, labyrinthine, in oto- 
sclerosis, 157 
Cardinal symptoms of aural 

disease, 47, 48 
Carotid artery, relations of, 242, 

243 
Catheter, Eustachian, ascertain- 
ing position of, 66, 67 
attachment of, to tip, 66 
method of holding, 66 
passing of, 65 
selection of, 63, 64 
Catheterization, accidents of, 71, 
72 
anatomy, 64 
anesthesia in, 65 



428 



INDEX' 



Catheterization in aural diseases, 
135, 141, 147, 152, 153, 162, 
170, 182 
causes of failure in, 69 
methods of, 70 
sounds, interpretation of, 70 
in middle-ear diseases, 135, 
136, 140, 145, 152 
Cavity, radical mastoid, cleaning 

of, 285 
Cells, exposing of, in mastoid 
operation, 223 
removal of, in mastoid opera- 
tion, 225-227 
Cellular type of mastoid, 191 
Cerebellar abscess, adiadokokinc- 
sis in, 363 
ataxia in, 361 
nystagmus in, 361-363 
overpointing in, 362 
paralysis of respiration in, 
363 
Cerebrospinal fluid, flow of, after 
Neumann labyrinth opera- 
tion, 342 
in meningitis, 349-352 
Cerumen, 55 

absence of, in otitis externa, 

112 
impacted, 105 

retention of, in exostosis, 122 
Ceruminous glands, 19, 105 

in furuncle, 116 
Cheatle's theory of sclerotic mas- 
toid, 195 
Childbirth, effect of, on otosclero- 
sis, 156 
Children, mastoiditis in, 205, 206 
Cholesteatoma, 249, 263, 320 
Chorda tympani, 32, 173, 188, 

252, 273, 370 
Chronic catarrhal otitis media, 
142 
purulent otitis media, 247 
Cicatricial tissue in O. M. P. 

Resid., 296 
Circumscribed labyrinthitis, caus- 
ation of, 320 
diagnosis of, 322 
pathology of, 320 
symptoms of, 321 
tests of function in, 321 



Circumscribed labyrinthitis, 
treatment of, 322 
meningitis, 344 
causation of, 345 
diagnosis of, 345 
prognosis of, 345 
symptoms of, 345 
treatment of, 346 
Cisterna of pia arachnoid, 347 
Clamps, Michel's, 218 

of tuning-forks, 76, 77 
Claudius, cells of, 41 
Cocaine, carbolic acid and men- 
thol, 183 
in exudative type of O. M. C. C, 
147 
Cochlea, anatomy of, 38-43 
cUseases of, 380, 381 • 
involvement of, in deaf-mutism, 

396 
modiolus of, 38, 39 • 
opening of, in labyrinthine 

drainage, 336 
turns or whorls of, 38-43 
Cochlear drainage in Neumann's 
operation, 342 
(hict, 40. See Scala mccHa. 
turns or whorls, location of, 24 
Cocks, diagnosis of aural tuber- 
culosis, 413 
Cold, application of, in mastoidi- 
tis, 213 
Compensation of labyrinthine 

function, 317 
Complement-fixation tests in aural 

syphilis, 406 
Complications of purulent otitis 
media, 178, 261, 262, 343 
treatment of, in skin graft, 292, 
293 
Condylomata of external ear, 402 
Cone of light, formation of, 57 
Connective tissue, formation of, 

in O. M. C. C, 148 
Constipation as cause of tinnitus, 

421 
Constitution, inferiority of, in 

O. M. P. C, 251 
Convulsions in O. M. C. A., 166 
Cortex, mastoid, inspection of, 
222 
removal of, 223, 224 



INDEX 



429 



Corti, organ of, in otosclerosis, 

157, 158, 160 
Cortical perforations of mastoid, 

202 
Cotton pledget for increasing 

hearing, 299 
Cough from foreign body in exter- 
nal meatus, 109 
from impacted cerumen, 
106 
Cretinism, relation of, to deaf- 
mutism, 395 
Crist ae ampuUse. 33 

physiology of, 300 
Crus commune, 35 
Culture of blood in sinus thi'om- 
bosis, 238 
of cerebrospinal fluid in men- 
ingitis, 349, 350 
method of making, of am'al pus, 

54 
of tubercular bacilli from aural 
pus, 413, 414 
Cupula, 40 

Cm-ette, dull ring, in removal of 
cerumen, 106, 107 
foreign bodies, 110 
use of, in operation on 
lateral smus, 241 
sharp ring in removal of aural 
poh^DS, 266 
in radical mastoid opera- 
tion, 285 
use of in extending antrum for- 
ward, 280 
mastoid operation, 225, 226 
in removing posterior over- 
hang, 282-284 
Curettes for mastoid operation, 

215 
Cm-rents in semicircular canals, 
gravitv, 310-315 
mertia, 303-309 
Cutaneous diseases of external 

ear, 89 
Cysts, sebaceous, 125 



Day, non-infective • thrombi of 
lateral sinus, 235 



Deaf-mutism, acquired, causes of, 
394, 395 
congenital, causes of, 394 
diagnosis of, 399 
pathology of, 396 
physician's dut}' in, 401 
symptoms of, 397 
treatment of, 405 
Deafness, in diseases of external 
ear, 97, 106, 115, 117, 124 
of middle ear, 134, 138, 144, 
149, 158, 166, 173, 251, 
. 297, 299 

of perceptive mechanism, 

158, 385, 387, 394, 397, 

405, 417 

relation of, to loss of static hri- 

tability, 380 

Decompression in meningitis, 353 

operation, 355 
Decubitus in serous and purulent 

lab}Tmthitis, 328 
Deflected septum, passing cathe- 
ter m patients with, 69 
Deformity after perichondritis of 

auricle, 104 
Dehiscence in Fallopian canal, 31, 
252 
in tegmen t^^mpani, 24 
Deiters's cells, 41 

nucleus, 43 
Delstanche's masseur, 155 
Dench, 136, 207, 247, 286, 421 
ear punch, 272 
fork, 76 

Gait on whistle, 78 
inflating apparatus, 64 
triangle, 196, 231, 276, 277 
Denker, 396 

Dermatitis of amicle, causation 
of, 93 
symptoms of, 93 
treatment of, 93 
Desquamative otitis externa, 112 
Diabetes, amal disease in, 179, 

213, 218 
Diffuse external otitis, 111 
Diphtheria as cause of O. M.P.A., 
171 
and eighth nerve lesions, 391 
Diplococcus in brain abscess, 357 
Diploetic type of mastoid, 193 



430 



INDEX 



Discharge, inspissated, 106 

intermittent, in extradural ab- 
scess, 344 

in mastoiditis, 205 
Disharmony of static mechanism, 

323, 324 
Divisions of ear, 17 
Dixon, 194, 195 
Dorello's canal, 375 
Douche, nasal, as cause of, O. M. 

P. A., 171 
Drainage in brain abscess, 364 

sufficiency of, method of ascer- 
taining, 61, 62 
Dressing for mastoid wound, 230 
Dry treatment of O. M. P. C, 

265 
Ductus endolymphaticus, 38, 45, 
384 
empyemia of, 327 
Dura, avoidance of injury to, 227 

discoloration of, in sinus throm- 
bosis, 237 

treatment of wounds of, 230 
Dwyer, 413 



Ear, anatomy and physiology of, 
17 
external, anatomy of, 17 

diseases of, 84 
inner, 33 

non-suppurative diseases of, 

379 
suppurative diseases of, 300 
middle, anatomy of, 22 

non-suppurative diseases of, 

132 
suppurative diseases of, 164 
Earache. See Pain in aural dis- 
eases. 
Eczema of external ear, causa- 
tion of, 91 
symptoms of, 91 
treatment of, 91 
Edema around auricle in fur- 
uncle, 117, 118 
Eighth nerve, anatomy of, 42 
central connections of, 44, 45 
lesions of, 379 



Eighth nerve, syphilis of, 404 
traumatic involvement of, 
417 
Electric light stand, 51 
Electricity in herpes zoster oticus, 
97 
in treatment of facial paralysis, 
372 
Elevator, periosteal, author's, 215 
Eminentia arcuata, 35 
Emphysema, submucous, from 

catheterization, 71 
Endolymph, 40 

currents of, 300, 324 
Enlarged lower turbinate, passing 

catheter in patients with, 69 
Entotic noises, 297, 422 
Epilepsy from foreign bodies, 109 
Erysipelas of external ear, 94 
diagnosis of, 94 
symptoms of, 94 
prognosis of, 94 
treatment of, 95 
Europe, diffuse external otitis in, 

113 
Eustachian applicator, 136 
tube, anatomy of, 25, 132 
caliber of, as shown by infla- 
tion sound, 70 
catarrh of, 132 
changes of, in tubotympan- 

ites, 137 
contraction of, as cause of 
rupture of drum mem- 
brane, 130 
cross-section of, 133 
dilatation of, with bougies, 

154 
involvement of, in O. M. 

P. C, 254 
pharyngeal orifice of, 65 
physiology of, 132 
stenosis of, in O. M. C. C, 
154 
in tubal catarrh, 134 
tenacious mucus in, 138 
treatment of, in radical mas- 
toid operation, 285 
tympanic opening of, 58 
Ewald's experiments, 303 
Exacerbation, acute, in O. M. 
P. C, 261, 262 



INDEX 



431 



Examination of patient, 47 

method of, 50 
Exostosis of external auditory 
meatus, 120 
causation of, 120 
diagnosis of, 122 
prognosis of, 122 
symptoms of, 121 
treatment of, 122 
Experimental nystagmus, 303 
External auditory canal, anatomj^ 
of, 19 
development of, 21 
nerve supply of, 22 
ear, dermatitis of, 93 
diseases of, 84 
eczema of, 91 
malformations of, 84 
neuralgia of, 98 
Extradural abscess, 228, 243, 244 
Eye-grounds, changes of, in brain 
abscess, 360 
in meningitis, 349 
in sinus thrombosis, 237 
muscles, action of, in nystag- 
mus, 301 
enervation of, 301 



Facial-hypo GLOSSAL anastomo- 
sis, 372-374 
nerve, anatomy of, 30 

avoidance of injury to, in 

mastoid operations, 227, 

281, 284 
involvement of, in aural 

syphilis, 407 
in labyrinthine drainage, 337 
paralysis, 368 

after myringotomy, 188 
after ossiculectomy, 273 
anastomosis in, 373 

indications for, 372 
chorda tympani in, 370 

diagnosis of, 371 
in herpes oticus, 95 
as indication for mastoid 

operation, 371 
manner of making taste tests 

in, 370 



Facial paralysis in O. M. P. C, 
252 
pathology of, 368 
prognosis of, 372 
S3^mptoms of, 369 
treatment of, 372 
ridge, lowering of, in radical 
mastoid operation, 284 
Factors producing 0. ]\1. C. A., 

166 
Falling in nystagmus, 362 
Fallopian canal, 23, 31 
Fehling's test of cerebrospinal 

fluid, 350 
Fenestrse, labyrinthine, avoid- 
ance of, in myringotomy, 186, 
187 
Fever in aural diseases, 103, 113, 
139, 166, 167, 173, 204, 205, 
209, 328 
Field, exposure of, in mastoid 
operation, 221 
in radical mastoid operation, 
276 
Fistula, congenital aural, 88 
of labyrinth, 320 
test, 316 
Fissure, auriculocranial, oblitera- 
tion of, in mastoiditis, 198 
Fissures in temporal bone of 

infants, 208 
Fixator, Barany's, 319 
Floccular fossa, 35, 198 
Floor of meatus, lowering of, in 
radical mastoid operation, 
284 
Folds of tympanic mucous mem- 
brane, 29, 30, 164 
Forceps, angular, 55 

for mastoid operation, 215, 217 
in removal of foreign bodies, 

110 
Scheibel's suture, 218 
Foreign bodies, in external audi- 
tory meatus, 105, 
108, 129, 130 
diagnosis of, 109 
posterior incision in 

removal of, 110 
symptoms of, 109 
treatment of, 110 
Fork, Bench, 76 



432 



INDEX 



Fossa, middle relation of, to mas- 
toid, 196 
subarcuata, 198 
Fracture of temporal bone, 341, 

416, 417 
French method of instructing 

deaf-mutes, 401 
Frost-bite of auricle, 93 
Fulness, feeling of, in ear, 134, 

138 
Functional tests of audition, 72 
of static labyrinth, 300 
caloric, 310 
fistula, 315 
galvanic, 315 
physiology of, 300 

Ewald's laws, 302 
rotation nystagmus, 303 
value of tests, 317 
caloric, 318 
compensation, 317 
Fundus, changes of, in mastoidi- 
tis, 206, 211 
Fungi in external auditory me- 
atus, 114 
Furuncle, counter opening in 
large, 119 
following removal of cerumen, 

108 
prevention of recurrence of, 120 
a result of diffuse otitis externa, 
112 
Furunculosis, constitutional treat- 
ment of, 120 



G 



Galton whistle, 77 

Galvanic test for irritability of 

static labyrinth, 315 
Ganglion of Scarpa, 42 

vestibular, 42 
Gauze retractor in radical mas- 
toid operation, 278, 279 
rolls, removal of, in after-treat- 
ment, 245, 246 
> in sinus thrombosis opera- 
tion, 240 
Gelle test, method of making, 83 

in otosclerosis, 162 
Geniculate ganglion, 32 



German method of teaching deaf- 
mutes, 401 
Glands, broken-down, in mastoid 

region, 212 
Globulins, serum, in meningitis, 

352 
Glossopharyngeal nerve, 25 
Goerke, 391 
Goldstein, 88 
Goris operation for abscess at 

petrous tip, 378 
Gouge, use of, in mastoid opera- 
tion, 224 
in opening the antrum, 277 
in taking down the l)ridge in 
radical operation, 280 
Gouges, mastoid, author's, 215, 

216 
Gradenigo, 377 
triad of, 375 
Grafted cavities, after-treatment 

of, 292 
Grafts, Ticrsch, 291, 292 
needle for teasing, 291 
razor for cutting, 291 
Granulations in after-treatment 
of radical cavities, 290, 292 
in extradural a])scess, 201, 202 
exuberant, in mastoid wounds, 

233 
in O. M. P. C., 249, 256 
osteoblastic, in mastoiditis, 195, 

201 
in tuberculosis of the middle 
ear, 410 
Greissinger's symptom, 238 
Gumma of the external ear, 402 
Gutter operation on the jugular 
bulb, 246 



Hair follicles in furuncle, 116 
Haversian canals in otosclerosis, 

157 
Headache in brain abscess, 358 

in meningitis, 348, 355 
Healing, delayed, of mastoid 

wounds, 233 
Hearing, tests for, 72 
Helicotrema, 40 



INDEX 



433 



Helmholz, ligaments of, 28 

theory of audition, 45 
Hematoma auris, 100 
diagnosis of, 101 
etiology of, 100 
symptoms of, 101 
treatment of, 102 
Hemorrhage into labyrinth, 382, 
383 
from lateral sinus after mastoid 
operation, 247 
arresting of, 241 
from mastoid emissary vein, 222 
from meatus, 416 
Henle, spine of, 196 
Henson, supporting cells of, 41 
Heredity in otosclerosis, 156 
Herpes of external ear, 95 
diagnosis of, 96 
herpes zoster oticus, 95 
prognosis of, 96 
symptoms of, 96 
treatment of, 97 
Hiatus FaUopii, infection through, 

in meningitis, 346 
His leukocyte extract in erysipe- 
las, 95 
in meningitis, 353 
Homohvoid muscle in jugular 

resection, 243, 244 
Horizontal semicircular canal, 
anatomy of, 34 
in radical operation, 281 
Hugier, canal of, 32 
Hunt, Ramsey, 95 
Hutchinson's teeth, 407 

triad, 407 
Hyperemia of labyrinth, 389 
causation of, 389 
diagnosis of, 389 
prognosis of, 390 
symptoms of, 389 
treatment of, 390 
Hyperostoses, 120 
Hysterical deaf-mutism, 399 



Illumixation for aural examina- 
tions, 50 
Impacted cerumen, 105 

28 



Impacted cerumen, causation of 
105 
diagnosis of, 106 
pathology of, 105 
prognosis of, 107 
symptoms of, 106 
treatment of, 107 
Impaired hearing as ascertained 
by acumeter, 73 
by voice, 75 
by watch, 72 
by whisper, 74 
Incision in mastoid operation, 
. 220, 221 
of membrana tympani, 142, 147, 
177, 179. A^ee Myringotomy, 
182. 
in radical mastoid operation, 
275, 276 
Incus, accidental, removal of, in 
mastoid operation, 227 
anatomy of, 27 
and stapes, avoidance of injury 

to, in myringotomy, 184 
removal of, in ossiculectomy, 
269-274 
Induced nystagmus, 303 
Infants, mastoid operation in, 
230, 231 
process in, 197, 198 
Infection in O. M. C. A., 166 
in traumatic rupture of the 
membrana tympani, 130 
Infectious diseases, as cause of 

O. M. P. A., 171 
Inflation, auto-, in O. M. P. A., 
176 
in O. M. P. C, 264 
of middle ear, 62 

catheterization, 63 
Politzer's method, 62 
Valsalva's method, 62 
Influenza as cause of otitis ex- 
terna hemorrhagica, 97 
Injuries to ear, 416 
to labyrinth, 326 
Inner ear, anatomy of, 33 
blood supply of, 42 
mode of dissecting, 33 
nerves of, 42 
Inoculation in diagnosis of aural 
tuberculosis, 412 



434 



INDEX 



Insanity as a cause of hematonia 

auris, 100 
Instruments for mastoid ojjera- 

tions, 214, 274 
Internal auditory meatus, fundus 
of, 43 
tympanic wall, 23 
Intertrig;o, causes of, 89 
symptoms of, 90 
treatment of, 90 
Intratympanic fluid, effect of, on 
hearinjz;, 138 
in O. M. C. C, 145 
otoscopic appearance of, 139 
in tubotympanites, 139 
lodin, cutaneous reactions fol- 
lowinji; use of, 94 
in preparation of field for mas- 
toid oi)erations, 219 
in treatment of exuberant gran- 
ulations, 233 
Iter chorda anterius, 32 
posterius, 32 



Jacobson's nerve, 25 
Jugular bulb, anomaly of, 25 
avoidance of injury to, in 

labyrinth operation, 338 
injury to, in mvringotomy, 
185, 187 * 
in ossiculectomy, 273 
vein branches of, 244 
relations of, 242-244 
resection of, 242 

after-treatment of, 240 
indications for, 242 
gutter operation, 246 



Kernig, sign of, 348 
Knife for myringotomy, 182 



Labyrinth, anatomy of, 33 
anemia of, 387 



Labyrinth, changes of, in deaf- 
mutism, 31K), 397 
concussion of, 417, 418 
diffuse purulent infhimmation 
of, 320 
serous inflammation of. 322 
divisions of, 17, il 
hyiK'remia of, 389 
injuries to, as cause of laby- 
rinthitis, 326 
leukemia of, 386 
nieml)ranous, changes of , in oto- 
sclerosis, 157 
distort ions of, in serous laby- 
rinthitis, 323 
non-su|)purativc diseases of, 
1 15(), 379 

I ojK'rations on, 332 
j choice of, 332 

instruments for, 334 
labyrinthine drainage, 334 
Neumann's operation, 339 
preliminary radical, 333 
position of, 33 
static, 17, 33 

functional tests of, 300 
suppurative disejuses of, 320 
syphilis of, 404 
tuluTculosis of, 415 
Labyrinthine drainage, 334 
after-treatment of, 339 
facial nerve in, 337 
guide to vestibule, 334 
(►j)ening cochlea in, 33t) 
horizontal semicircular 

canal in, 335 
vestibule in, 33() 
second cochlear whorl in, 338 
hemorrhage, 383 
etiology of, 383 
diagnosis of, 385 
pathology of, 384 
prognosis of, 386 
svm])toms of, 385 
treatment of, 386 
pressure, increase of, in tubal 
catarrh, 135 
mechanism for regulating, 45, 
46 
Labyrinthitis a cause of brain 
abscess, 357 
of meningitis, 347, 353 



INDEX 



435 



Labyrinthitis, circumscribed, 320 

from foreign bodies, 109 
Lamina propria, inflammation of, 
in myringitis, 128 
spiralis ossea, 39 
Landmarks of membrana tym- 
pani, 56 
loss of, in O. M. P. A., 177 
Language of deaf-mutes, methods 

of teaching, 401 
Latent meningitis, 348, 352 

purulent labjTinthitis, 326 
Lateral sinus, injury of, 236 
Laws, Ewald's, 303 
Leeches in treatment of mastoid- 
itis, 214 
Leontiasis ossea as a cause of 

exostosis, 121 
Leptomeningitis, purulent, 346 
Leukemic disease of ear, 384, 386 
Leukocytes in spinal fluid in 

meningitis, 350-352 
Levator palati, action of, 132 
Lewin, 392 

Ligament um spirahs, 39 
Ligatures for jugular resection, 

244 
Light for aural examinations, 50 
position of, 52 

reflex of membrana tympani, 59 
Lombard, 376 

Lower-tone limit, determination 
of, 76 
significance of elevation of, 
77 
Lumbar puncture, 355 
after-effects of, 356 
in diagnosis of meningitis, 

349, 351 
position of the patient for, 
355 
Luster, cause of absence of, 59 

of membrana tensa, 59 
L3'mph nodes, cervical, in aural 
tuberculosis, 410 



M 

MacEwen, triangle of, 195 
MacKernon's forceps, 217, 228, 
240 



Macrotia, 84 

operations for, 85 
Malaria, diagnosis of sinus tn^-om- 

bosis from, 238 
^Malformations of external ear, 48 
Malleo-incudal articulation, 27 
Malleolar, 58. See Manubrial. 
Malleus, anatomy of, 25-27 
handle, 25, 26, 56. See Manu- 
brium, 
ligaments of, 28 
removal of in ossiculectomy, 

269-274 
rotation of, 154, 253, 398 
short process of, 25, 56 
Manasse, 156, 396 
Al audible, influence of move- 
ment of, on cerumen, 105 
Alanifest purulent labvrinthitis, 

326 
^Manubrial plexus, 58 
Manubrium, 25, 56, 58 
Massage in treatment of facial 

paralysis, 372 
Mastication, pain during, in 

otitis externa, 113, 117 
Mastoid abscess, definition of, 
203 
locations of rupture of, 201- 
203 
anatomy of, 189 
antrum, 195 

in diploetic bones, 193 
landmarks of, 196 
in infants, 197 
lateral sinus, 197 
middle fossa, 196 
variations, 189 
diploetic type, 193 
pneumatic type, 191 
sclerotic type, 193 
cells, intercommunication of, 

200 
dressings and intertrigo, 90 
infantile type of, 195 
operation, 214 

after-treatment, 232 
blood-clot treatment of 

wound, 234 
delayed healing, 233 
extradural aVjscess, 228 
facial nerve, 227 



436 



INDEX 



Mastoid operation, granulations, 
233 
incision, 220 

exposure of field, 221 
posterior incision, 222 
indications for, 203-212, 214 
in infants, 230 
injury to dura, 230 

to sinus, 229 
inspection of the cortex, 222 
instruments for, 214 
preparation of patient, 218 
anesthesia in, 219 
position of patient, 219 
prognosis, 234 
removal of cells, 225 
of cortex, 223 
of tip, 225 
scars as cause of otalgia, 99 
sclerosis of, 194, 195 
wounds, erysipelas in, 95 
Mastoiditis, 199 

Bezold's type of, 192 
causation of, 200 
definition of, 199 
diagnosis of, 208 
from furuncle, 118 
from otalgia, 99 
hemorrhagic form of, 210 
pathology of, 200 

location of rupture, 201 
prognosis of, 212 
subacute, in infants and chil- 
dren, 205 
symptoms of, 203 
treatment of, 213 
without apparent middle-ear 
involvement, 212 
Mathieu's rongeur forceps, 217 
Mauthner, traumatism of inner 

ear, 418 
Measles as a cause of aural dis- 
ease, 171, 391 
Meatus, external auditory, atre- 
sia of, 124 
examination of, 53, 54 
in infants, 198 
method of straightening, 
in aural examinations, 
55 
occlusion of, in exostoses, 
121, 122 



Meatus, external auditory, occlu- 
sion of, in furuncle, 117 
posterior wall of, in radical 

operation, 277 
shortening of, in mastoidi- 
tis, 207 
strictures of, 124 
superior wall of, relation 
to middle fossa, 279, 
280 
flaps of Ballance, 286 

Dench modification of Bal- 
lance, 286 
Korner, 289 

method of forming, 286-289 
Pause, 289 
Mechanism, perceptive, diseases 

of, 379 
Meckel, band of, 28 
Medicolegal aspect of traumatic 
lesions of inner ear, 417 
of rupture of membrana 
tympani, 131 
Membrana tensa, color of, 58 
cone of Hght of, 56 
luster of, 59 
position of, 59 
quadrants of, 57 
structure of, 22, 61 
total absence of, 61 
tympani, 19, 20, 22 

artificial opening in, in O. 

M. C. C, 155 
in aural diseases, 109, 115, 
117, 118, 134, 135, 139, 
149, 167, 174, 175, 252- 
263, 403, 411 
diseases of, 127 

acute myringitis, 127 
chronic myringitis, 129 
rupture, traumatic, 129 
examination of, 55-62 
color, 58 
integrity, 60 
luster, 59 
position, 59 
structure, 61 
incision of, 142, 147, 182, 416. 

See Myringotomy, 
landmarks of, 56 
secondaria, 24 
of Reisner, 39 



INDEX 



437 



Membrane, tectorial, 41 
Membranous atresias of external 

meatus, 124, 125 
Meniere's disease, 383 
symptom-complex, 382 

in herpes zoster oticus, 
95 
Meningismus, 353, 355 
Meningitis, 343 

after ossiculectomy, 273 

circumscribed, 344 

epidemic * cerebrospinal and 

inner-ear disease, 391, 392 
external pachymeningitis, 343 
from foreign bod}^, 109 
. latent, 348 
purulent leptomeningitis, 346 
serous, 353 
Metastatic abscesses in sinus 

thrombosis, 239 
Meyer, Otto, statistics of aural 

syphilis, 404 
Michel's clamps, 218 
Microtia, malformations in, 85 

operations for, 86 
Middle ear, anatomy of, 22. See 
Tympanum, 
arteries of, 30 
epithelium of, 30 
inflammation of. See Otitis 

media, 
mucous membrane of, 29 
nerves of, 30 
non-suppurative diseases of, 

132 
syphilis of, 403 
tuberculosis of, 409 
waUs of, 22 
Mirror for aural examinations, 

51, 52 
Modified radical operation, 294 
Modiolus, avoidance of injury to, 
in labyrinthine operation, 
337 
meningeal processes in, 39 
Mosetig-Moorhof, plastic opera- 
tion, 293 
Mosher, 268 

Mucous membrane, tubal, appli- 
cations to, 136 
in tubal catarrh, 133 
loss of epithelium of, 171 



Mucous membrane, tympanic, 
folds of, 29, 143, 149, 164, 172 
Mucus, tenaceous, in exudative 
type of O. M. C. C, 147 
in tubal catarrh, 136 
Mumps, aural lesion in, 392 
Murmurs, vascular, 422 
Mutism, 394 
Mygind, 396 
Myringitis, acute, 127 
diagnosis of, 128 
etiology of, 127 
prognosis of, 128 
symptoms of, 128 
treatment of, 128 
chronic, diagnosis of, 129 
symptoms of, 129 
treatment of, 129 
Myringotomy , 182 
accidents of, 187 
anatomy of, 185 
anesthesia in, 183 
asepsis during, 182 
incision, method of making, 185 

sufficiency of, 187 
indications, 177, 179 
method of holding the knife, 

184 
as preventative of mastoiditis, 

213 
second, when justifiable, 180 
without anesthesia, 183 



N 

Nasopharynx in aural diseases, 
136, 142, 147. See also Ade- 
noids. 

Neck, stiffness of, in mastoiditis, 
208 
in meningitis, 349 

Needle for spreading Tiersch 
grafts, 291 

Nerve, auricularis magnus, in 
otalgia, 98 
auriculotemporal, in otalgia, 98 
eighth, diseases of, 379 

in otosclerosis, 157 
small occipital, in otalgia, 98 

Nerves, anatomy of, carotico- 
tympanic, 30 



438 



INDEX 



Nerves, anatomy of, eighth, 42- 
45 
glossopharyngeal, tympanic 

branch, 30 
facial, 31 
large deep petrosal, 32 

superficial petrosal, 32 
pars intermedia of Wrisberg, 

32 
ramus-communicus, 30 
small deep petrosal, 30 
Vidian, 32 
Neumann, 357 

operation on labyrinth, 339 
after-treatment of, 342 
cochlear drainage in, 342 
locating vestibule in, 339 
opening internal auditory 

meatus, 340 
vestibule in, 339 
Neuralgia of ear, 98. See Otalgia. 
Neurorecurrences after salvarsan, 

408 
Nichol's theory of neurorecur- 
rences, 408 
Noise apparatus, Barany's, 75 
Noises, entotic, 422 

subjective, 419 
Non-suppurativc diseases of inner 
ear, 379 
anemia of labyrinth, 387 
causation of, 379 
deaf-mutism in, 399 
general considerations 

of, 379 
hyperemia of labyrinth 

of, 389 
labyrinthine h e m o r - 

rhage, 383 
leukemia of inner ear, 

386 
Meniere's symptom - 

complex, 382 
otitis interna, 390 
symptoms of, 380 
middle ear, 132 
Nucleus accessory, 44 
Bechterew's, 43 
Deiters's, 43 
external, 43 
motor ocuH, 44, 301 
Nystagmus, 301, 302 



Nystagmus in aural disease, 321, 
323, 328, 331, 417 

in cerebellar abscess, 361 

designation of, 306 

physiological, 48, 50 

production of, by galvanism, 
315 
by rotation, 303 
by syringing the ear, 310 

rules for determining the direc- 
tion of, after rotation, 306 



O. M. C. A. Sec Otitis media 

catarrhalis acuta. 
O. M. C. C. .SV(i Otitis media 

catarrhalis chronica. 
O. M. P. A. See Otitis media 

purulenta acuta. 
O. M. P. C. See Otitis media 

purulenta chronica. 
O. M. P. Resid. See Otitis media 

l)urulenta residua. 
Opisthotonos, 349 
Organ of Corti, 40, 41 
Osteitis metai)lastica, 156 
Otalgia, causes of, 98 
diagnosis of, 99 
j)rognosis of, 99 
symptoms of, 99 
treatment of, 100 
Othematoma, 100 
Otitic brain abscess, 356 
Otitis externa circumscripta, 
causation of, 116 
diagnosis of, 117 
symptoms of, 117 
treatment of, 119 
diffusa, deep form, diagnosis 
of, 113 
pathology of, 113 
prognosis of, 113 
symptoms of, 113 
treatment of, 113 
superficial form, symp- 
toms of, 112 
treatment of, 112 
hemorrhagica, diagnosis of, 
97 
prognosis of, 98 



INDEX 



439 



Otitis externa hemorrhagica, 
S3^mptoms of, 97 
treatment of, 98 
interna, definition of, 390 
diagnosis of, 393 
etiolog}' of, 391 
prognosis of, 394 
symptoms of, 392 
treatment of, 394 
media, acuta, 164 

catarrhalis acuta, diagnosis 
of, 167 
etiology of, 165 
pathology of, 166 
prognosis of, 169 
signs of, 167 
SA^mptoms of, 166 
treatment of, 169 
t3^pes of, 168 
chronica, 142 

exudative tvpe, causa- 
tion of, ^143 
diagnosis of, 146 
pathology of, 143 
prognosis of, 146 
signs of, 144 
symptoms of, 144 
treatment of, 147 
hyperplastic type, caus- 
ation of, 148 
diagnosis of, 146 
inflation in, 152 
patholog}' of, 148 
prognosis of, 153 
signs of, 151 
symptoms of, 149 
treatment of, 153 
pm-ulenta acuta, 170 
diagnosis of, 177 
etiology of, 170 
pathology of, 171 
prognosis of, 178 
signs of, 174 
symptoms of, 172 
treatment of, 179 
chronica, 249 
causation of, 249 
comphcations of, 261 
diagnosis of, 262 
pathology of, 249 

cholesteatoma, 249 
prognosis of, 263 



Otitis media purulent a chronica, 
signs of, 252 
symptoms of, 250 
treatment of, 263 

indications for opera- 
tion, 267 
removal of polyps, 265 
Yankauer's operation, 
268 
residua, causation of, 296 
diagnosis of, 298 
otoscopic appearances, 

297 
pathology of, 296 
prognosis of, 298 
svmptoms of, 297 
treatment of, 298 
Otomycosis, causation of, 114 
diagnosis of, 115 
prognosis of, 116 
s^miptoms of, 114 
treatment of, 116 
Otosclerosis, causation of, 156 
diagnosis of, 159 
pathology of, 157 
prognosis of, 162 
symptoms of, 158 
treatment of, 162 
Otoscope, in extradural abscess, 
344 
Siegel's, 60, 61 
Otoscopic appearance in aural 
diseases, 106, 115, 135, 139, 
144, 151, 174, 206, 252-261, 
297, 411 
Ossicles, 25, 26 

Ossicular chain, ligaments of, 27 
rigidityofinO. M.C. C, 149 
movements, mechanism of, 28 
Ossiculectomy^, 269 
accidents of, 273 
after-treatment of, 273 
anesthesia in, 270 
indications for, 269 
modification of, for non-sup- 

purative cases, 274 
results of, 274 
Oval window, 23 
Overinflation, 152 
Overpointing in cerebellar abscess, 

362 
Overtones in tuning-forks, 77 



440 



INDEX 



Pachymeningitis externa, 343 
diagnosis of, 344 
treatment of, 344 
Page, John Randolph, 86, 87, 400 
Pain, aural, in disease of ear, 99, 
103, 112, 113, 115, 117, 128, 
138, 166, 167, 168, 172, 203, 
204, 209, 343, 348 
Pan otitis, 327 
Panse meatal flap, 289 
Paper splint for healing perfora- 
tions of drum membrane, 299 
Paracusis Willisii, 150, 159 
Paralysis, crossed in brain ab- 
scess, 361 
of external rectus oculi, 374 
of facial muscles, 369 
Passow-Trautmann, plastic oper- 
ation, 293 
Pedro de Ponce, 401 
Perception of pitch, 45 
Perceptive mechanism, diseases 
of, 379 
involvement of, in otoscle- 
rosis, 158, 160, 161 
Perforations of membra na tym- 
pani, conical, in mastoid- 
itis, 207 
method of locating, 60, 61 
in O. M. P. C, 252-261 
traumatic, 129-131 
in tuberculosis, 411 
Perichondritis of auricle, diagnosis 
of, 103 
etiology of, 102 
pathology of, 102 
prognosis of, 103 
S3^mptoms of, 103 
treatment of, 103 
Perilabyrinthitis, 330 
diagnosis of, 331 
pathology of, 330 
prognosis of, 331 
S3^mptoms of, 331 
treatment of, 332 
Perilymph, 40 
Periosteal elevator, 215 
Periostitis of mastoid process, 199 
Perkins's Eustachian bougies, 154 
gouges and chisels, 215, 216 



Perkins's lab>Tinth gouges and 
chisels, 333 
periosteal elevator, 215 
Petroff, media of, 413, 414 
Petrosal branches of tympanic 
plexus in meningitis, 346 
nerves, 32 

sinus, thrombosis of, causing 
abducens paralysis, 376 
Petrous tip, involvement of, in 

abducens paralysis, 376 
Phase of semicircular canals and 
I la])yrinth, 317 
j Physiology- of audition, 44 
I of ossicular movements, 28 

of the ear, 17 
Pilocarpine, mode of administra- 
I tion of, 332 
' Pinna, 17 

I Plexus, tympanic, 30 
! Pneumatic type of mastoid, 191 
i Pneumococcus, 178, 202. 
Pneumogastric nerve, 242-244 
Pneumomassage in O. ]\I. P. 

Resid. 299 
Politzer,'97, 101, 163, 200, 261, 

270, 327, 344, 389^ 
Politzer's acumeter, 73 

method of inflation, 62 
1 Polymorphonuclear cells in men- 
ingitis, 350, 351 
Polyotia, 84 

j Polyps, aural, meningitis fol- 
j lowing removal of, 266, 

346 
removal of, 265 
j Posterior openings after radical 
I mastoid, 293 
' Pouches oif von Troltsch, 29 
I Processus cochleariformis, 24 
I Promontory of cochlea, 24, 38 

removal of, in labyrinth oper- 
I ation, 336 

Prussak's space, anatomy of, 29 
exhausted suppuration of, 
261 
Pulmonary embolism in mastoid- 
itis, 235 
Pulse in brain abscess, 359 
Purulent labjTinthitis, 326 
causation of, 326 
panotitis, 327 



INDEX 



441 



Purulent lab^Tinthitis, patholog\' 
of, 327 
prognosis of, 329 
sequestration in, 329 
symptoms of, 328 
treatment of, 329 
leptomeningitis, causation of. 
346 
course and s^nnptoms of, 3 48 
diagnosis of, 349 
pathology- of, 347 
prognosis of, 352 
treatment of, 352 
Pus in brain abscess, character- 
istics of, 357 
Pvocvaneus, as cause of perichon- 
^Iritis. 102 i 



Quadrants of membrana tym- 

pani, 57 
Quinine and inner-ear disease, 

379, 380 



R 



Radical mastoid operation, 274 
after-treatment of, 289, 

292 
cleaning ca^-ity, 285 
Eustachian tube in, 285 
exposing field in, 276 
forming and taking down 

bridge in, 279 
incision iu, 275 
instruments for, 274 
lowering facial ridge in, 384 

floor in, 384 
meatal flap iu, 286 
modification of, 294 
opening the antrum. 276 
prehminarv' to lab^Tinth 

operation, 333 
preparation of patient for, 

275 
posterior openings, 293 
removing the overhang, 

282 
results of, 294 i 



Radical mastoid operation, skin 

graft in, 290 
Rapid component of nystagmus, 

303 
Razor for cutting epithelial 

grafts, 291 
Recesses of von Troltsch, 29 
Recessus eUipticus. 38 

sphericus. 38 
Reflex light of membrana tym- 

pani. 59 
Reisner's membrane, 39 
Relation of facial nerve to hori- 
zontal semicircular canal, 
336 

of superior canal wall to middle 
fossa, 279, 280 
Residual processes in the middle 

ear, 296 
Respiration, Cheyne-Stokes, 360 

paralysis of, in cerebeUar ab- 
scess, 363 
Retractors, gauze. 277, 278 

mastoid. 215 
Rhioitis, atrophic, as cause of 

O. M. P. A., 171 
Richards. Dr. John, 39, 337 
Richards's curettes. 274, 275, 284 
Rinne test. 80. 81 
Ri^-inus, segment of, 21 
Rosenthal's canal, 39 
Rotation nvstagmus, 304-309, 

317 
Roimd window, 24 
Rupture of membrana tympani 
during catheterization. 71, 72 

spontaneous, of brain absce.ss, 
358 
Ruttin, 318, 328 



Saccule. 38, 40 

Salvarsan in aural syphilis, 408 

Santee, 44 

Santorini, incisures of, 19 

Scala media, 40 

tympani, 39 

vestibuli, 40 
Scarlatina and aural disease, 171, 

391 



442 



INDEX 



Scarpa, ganglion of, 42 
SchiebeFs suture forceps, 218 
Schwabach test, 81 
Schwartze, 214. See Mastoid 

operation. 
Sclerotic type of mastoid, 193, 

194, 195 
Sebaceous cysts, 125, 126 
Semicircular canal, horizontal, in 
the labyrinth operations, 335, 
339 
canals, planes of, 36 

relation to axis of temporal 
bone, 37 
to each other, 36 
Secondary mastoid operation, 232 
Serous labyrinthitis, 322 
diagnosis of, 324 
pathology of, 323 
prognosis of, 325 
symptoms of, 323 
treatment of, 325 
meningitis, 353 

in brain abscess, 354 
causes of, 353 
diagnosis of, 354 
pathology of, 354 
prognosis of, 355 
treatment of, 355 
Short process of malleus, 25, 56 
Shrapnell's membrane, 22, 56 

perforations of, 258 
Siebenmann, 163 
Siegel's otoscope, 60, 61 
Sign, Babinski, 349 

Kernig, 348 
Sinus, avoidance of injury to, in 
mastoid operation, 225-227 
injury to, treatment of, 229 
lateral, relations of, to mastoid, 

197 
operation, exposure of sinus in, 
240 
incision of sinus in, 240 
removing clot in, 241 
thrombosis, causation of, 235 
diagnosis of, 338 
prevention of, 240 
prognosis of, 239 
symptoms of, 237 
treatment of, 240 
tympani, 24 



I Sinuses, accessory of nose and 
I O. M. P. A., 170 
Sixth cranial nerve, relations of, 
; 374, 375 

I Skiagraphic plates, 197. See 
I X-ray. 

Skin graft of radical mastoid 
; cavity, 290-293 
Slow component of nystagmus, 
; 302 

' Smear, method of making, 54 
Solutions for testing taste sense, 

370 
Sound-conducting apparatus, 17, 
i 76 

perceiving ap]:)aratus, 76 
Sj)eculum, aural, 53 

method of introducing, 53 
Speech, loss of, with deafness, 394 
Spherical recess of the vestibule, 

38 
Spiral canal, 39 
ganglion, 39 

in her])es oticus, 96 
in otosclerosis, !()() 
Splint, paj)er, for healing perfora- 
tions of mombrana tympani, 
299 
Spontaneous nystagmus, 303 
Spratt's curettes, 215, 216 
Spur facial, formation of, 284 
Stacke-Schwartze, 274. See Rad- 
ical mastoid operation. 
Stalk in brain abscess, 356 
Stapedio vestibular articulation, 

27 
Stapedhis muscle, 24, 27 

action of, 29 
Stapes, anatomy of, 27 

avoidance of injury of, in 
radical mastoid operation, 
285 
motility of, in O. I\L C. C, 149 

in otosclerosis, 157 
necrosis of, in O. M. P. C, 256 
Staphylococcus in furuncle, 116 

in perichondritis, 102 
Static labyrinth, function tests of, 
300 
caloric test, 310 
fistula test, 316 
galvanic test, 315 



INDEX 



443 



Static labjnrinth, function tests I 
of, rotation test, 303 ! 

mechanism in deaf-mutism, 398 
Stenosis of Eustachian tube, 149 i 
Streptococcus capsulatus, 178, 

202 
Strictures and atresias of exter- 
nal, auditory meatus, 
124 
diagnosis of, 125 
pathology of, 124 
symptoms of, 124 
treatment of, 125 
Strychnine in concussion of laby- 
rinth, 418 
Subarcuate fossa, 35, 198 
Subjective noises, 419 
Subnormal pulse and tempera- 
ture in brain abscess, 359 
Superior semicircular canal, 35 
Supernumerary auricle, 84 
Superoposterior wall of meatus in 
^ mastoiditis, 206, 211 
Suppuration, acute, of middle ear. 
See Otitis media purulenta 
acuta, 
chronic, of middle ear. See 
Otitis media purulenta 
chronica, 
of middle ear, recurrent, m 
children, 206 
Suppurative disease of labyrinth, 

300 
Symptoms, cardinal, of aural dis- 
ease, 47 
Syphilis of ear, 402 

external condylomata of, 402 

gumma of, 402 
inner, course and sj^mptoms 
of, 404 
diagnosis of, 406 
pathology of, 404 
prognosis of, 407 
. salvarsan and eighth nerve 
lesions, 408 
treatment of, 408 
membrana tvmpani, 403 
middle, 403 ^ 
Syringe, aural, for cleaning the 
vault, 265 
for impacted cerumen, 108 
for O. M. P. A., 180 



Taste paths, 32 

Tectorial membrane, 41, 45 

Teeth, carious, as cause of otalgia, 

99 
Temperature after jugular resec- 
tion, 246 
after mastoid operation, 232 
in brain abscess, 359 
in meningitis, 348 
in sinus thrombosis, 237 
Temporomaxillary articulation, 
disease of, as cause of otalgia, 
99 
Tenderness on pressure in fur- 
uncle, 118, 204 
m mastoiditis, 204, 209 
Tensor palati, action of, 132 

tympani, 25, 29 
Test, Ring's, 83 
caloric, 310 

complement-fixation, 406 
fistula symptom, 316 
functional, of audition, 72 
of static labjTinth, 300 
galvanic, 315 
GeUe, 83 
Rinne, 80 
rotation, 303 
Schwabach, 81 ^ 
of taste sense, 370 
AYeber, 82 
Thickening over mastoid, 207, 

211 
Thiersch grafts, 123, 275 

preparation of thigh for, 275 
Thrombi, non-infective, of lat- 
eral sinus, 235 
Thrombophlebitis of lateral sinus, 

235 
Tinnitus aurum, 419 

in aural diseases, 97, 106, 
115, 117, 121, 124, 
128, 130, 134, 139, 
144, 151, 159, 166, 
240, 251, 297, 382, 
385, 387, 405 
causes of, 419 
entotic noises, 422 
prognosis of, 421 
treatment of, 421 



444 



INDEX 



Tinnitus aurum in aural dis- 
eases, variety of noises 
in, 419 
vascular murmurs, 422 
Tip, mastoid, freeing and removal 

of, 222, 225 
Tone gaps, 78, 79 

islands, significance of, 78, 79 
limits, tests for, 76, 77 
in aural diseases, 134, 139, 
144, 150, 160, 381, 382 
Tonsils, enlarged, as cause of O. 
M. P. A., 171 
inflamed, as cause of otalgia, 99 
Torticollis in mastoiditis, 208 
Trauma as a cause of hematoma 

auris, 100 
Traumatic lesions of ear, 416 
external, 416 
inner, 417 

diagnosis of, 417 
medicolegal, 417 
prognosis of, 417 
treatment of, 418 
middle, 416 
rupture of membrana tympani, 
129 
causation of, 129 
diagnosis of, 130 
medicolegal, 131 
prognosis of, 130 
symptoms of, 130 
treatment of, 131 
Trautmann's triangle, 366 
Tubal catarrh, causation of, 132 
diagnosis of, 135 
pathology of, 133 
prognosis of, 135 
signs of, 135 
symptoms of, 134 
treatment of, 135 
Tube, Eustachian, methods of 

closure of, 268 
Tuberculosis of ear, 409 
external, 409 
inner, 415 

middle, causation of, 409 
diagnosis of, 411 
pathology of, 410 
prognosis of, 414 
signs of, 411 
symptoms of, 410 



Tuberculosis of ear, middle, 

treatment of, 415 
Tuberculum acusticum, 44 
Tubotympanic congestion, 137 
Tubotympanites, 137 

causation of, 137 

diagnosis of, 140 

pathology of, 137 

prognosis of, 141 

signs of, 139 

symptoms of, 138 

treatment of, 141 
Tuning-fork for testing bone con- 
duction, 79 
Twitching of facial muscles in 

radical operation, 283 
Tympanic membrane, divisions 
of, 22 
examination of, 55 

plexus, 30 
in otalgia, 98 

ring, 21 
Tympanum. See also Middle 
ear. 

air pressure in, 132 

walls of, 24 



Upper-tone limit, 77 

recording of, 78 

significance of lowering of, 
78 
Urotropin in meningitis, 353 
Utricle, 38 



V-SHAPED piece, removal of, in 

radical operation, 281, 282 
Vaccine, autogenous, in furuncu- 
losis, 120 
treatment of O. M. P. C, 264 
Valsalva's method of inflation, 54, 

62 
Vascular murmurs, 422 
Vault of tympanum, 164 

involvement of, in O. M. 
P. A., 172 



INDEX 



445 



Vertigo in aural diseases, 106, 130, 
135, 151, 159, 173, 252, 321, 
323, 328, 331, 385, 387, 388, 
405, 417 
Vestibular branch of eighth, in- 
volvement of, in herpes oti- 
cus, 96 
ganglion, 42 
nerve, 42, 43 
Vestibule, anatomy of, 37, 38 

guides to, in labvrinth opera- j 

tions, 336, 339 | 

Voice as a test for hearing, 75 i 

Volatile substances in treatment I 

of tubotympanites, 141 
Vomiting in intracranial disease, * 
348, 359, 
in labvrinthine disease, 323, 
328, 385 
Von Pirquet reaction in aural 
tuberculosis, 412 



W 

Wassermann reaction in aural 

syphilis, 406 
Watch tests for hearing, 72 
Weber test of bone conduction, 82 
^Miisper as a test for hearing, 74 



^Tiistle, Galton, for determining 
upper-tone limit, 77, 78 

Wliiting, 215, 357 

WiUisii, paracusis, 150, 159 

Wilson, 361 

Wittmak, 347 

Wounds of auricle, 416 

penetrating, as a cause of laby- 
rinthitis, 326 

Wrisberg, pars intermedia of, 96 



X-RAY plates in differential diag- 
nosis of furuncle and mas- 
toid, 119 
of sclerotic mastoids, 194, 195 
of teeth in otalgia, 100 



Yaxkauer's operation for tubal 

closm-e, 268 
Yansen, 349 

mastoid retractors, 215, 216 



Zoster, herpes, oticus, 95 









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